Provider Demographics
NPI:1265968259
Name:DEOL, KENNY
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:
Last Name:DEOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-9215
Mailing Address - Country:US
Mailing Address - Phone:209-485-7038
Mailing Address - Fax:
Practice Address - Street 1:3450 BROOKSTONE DR
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-9215
Practice Address - Country:US
Practice Address - Phone:209-485-7038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator