| NPI |
1609171776 |
|
| Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN |
|
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Organization Name Legal Business Name |
KENOLY EMERGING TECHNOLOGIES, LLC |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider First Line Business Practice Location Address |
2644 ARUNDEL RD |
The name of the organization provider. If the provider is an organization, this is the legal business name. |
| Provider Business Practice Location Address City Name |
COLLEGE PARK |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
GA |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address Postal Code |
303374908 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Telephone Number |
4043227591 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
1/20/2011 |
The telephone number associated with the location address of the provider being identified. |
| Last Update Date |
1/20/2011 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
KENOLY |
The date that a record was last updated or changed. |
| Authorized Official First Name |
MARILYN |
The first name of the authorized official. |
| Authorized Official Title or Position |
PRESIDENT |
The first name of the authorized official. |
| Authorized Official Telephone Number |
4043227591 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
335E00000X |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Organization Subpart |
N |
|