Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath | 96-481 | AZ |
N | 175L00000X | Homeopath | 96-481 | AZ |
NPI | 1306906060 |
---|---|
Provider Name | Dr. Kenneth Jason Proefrock |
First Address | Surprise, AZ 85374-3874 |
Second Address | Surprise, AZ 85374-3874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/12/2006 |
Last Update Date | 04/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
MP0541474 | DEA REGISTRATION NUMBER (01) | AZ |