Basic Information
| Provider Information | |||||||||
| NPI: | 1821280413 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KENNEDY | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 315 | ||||||||
| Address2: | TRINITY REHABILITATION, INC. | ||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012069195 | ||||||||
| FaxNumber: | 6019578391 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 W CHERRY ST | ||||||||
| Address2: | CHOCTAW COUNTY NURSING HOME | ||||||||
| City: | ACKERMAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622856235 | ||||||||
| FaxNumber: | 6019578391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 08/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0755 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09014160 | 05 | MS | MEDICAID |