Provider Demographics
NPI:1063061844
Name:MACKILLOP, KENNETH S (ATS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:MACKILLOP
Suffix:
Gender:M
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3421 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-8243
Mailing Address - Country:US
Mailing Address - Phone:802-999-6225
Mailing Address - Fax:
Practice Address - Street 1:3421 LAKE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:VT
Practice Address - Zip Code:05445-8243
Practice Address - Country:US
Practice Address - Phone:802-999-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program