Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 13778 | TX |
NPI | 1073000147 |
---|---|
Provider Name | Joe Daniel Kennedy |
First Address | Fort Worth, TX 76131-1133 |
Second Address | Fort Worth, TX 76131-1133 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2018 |
Last Update Date | 15/04/2018 |