Provider Demographics
NPI:1023226933
Name:YOUNGBLOOD, KENNETH EUGENE (PTA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:EUGENE
Last Name:YOUNGBLOOD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 SOUTH 8TH STREET
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014
Mailing Address - Country:US
Mailing Address - Phone:478-934-4013
Mailing Address - Fax:229-868-2175
Practice Address - Street 1:136 WEST DYKES STREET
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-934-8801
Practice Address - Fax:229-868-2175
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant