Basic Information
| Provider Information | |||||||||
| NPI: | 1053662361 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUGGER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | GARRETT | ||||||||
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| Credential: | ATC, PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 CROSSLAKE DR STE B | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124760409 | ||||||||
| FaxNumber: | 8124761016 | ||||||||
| Practice Location | |||||||||
| Address1: | 5625 PEARL DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477128106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127597493 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2012 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06006142A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 2255A2300X | 36001954A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.