1124678578 NPI number — KENNETH ANDRE ROBERTS II MA, RD, LDN

Table of content: KENNETH ANDRE ROBERTS II MA, RD, LDN (NPI 1124678578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124678578 NPI number — KENNETH ANDRE ROBERTS II MA, RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
KENNETH
Provider Middle Name:
ANDRE
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
MA, RD, LDN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124678578
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
922A TALON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
O FALLON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62269-1848
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-671-6501
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
922A TALON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-1848
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-688-2038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  2019029751 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X , with the licence number: 164.007826 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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