Provider Demographics
NPI:1104803139
Name:PEREZ, KENNETH DELORIA (RPT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:DELORIA
Last Name:PEREZ
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:MR
Other - First Name:KENNETH RAYMOND
Other - Middle Name:DELORIA
Other - Last Name:PEREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPT
Mailing Address - Street 1:5214 S EAST ST
Mailing Address - Street 2:BLDG D, STE 1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1917
Mailing Address - Country:US
Mailing Address - Phone:800-486-4449
Mailing Address - Fax:317-780-3745
Practice Address - Street 1:5214 S EAST ST
Practice Address - Street 2:BLDG D, STE 1, HTS OUTPATIENT THERAPY SERVICES
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1917
Practice Address - Country:US
Practice Address - Phone:800-486-4449
Practice Address - Fax:317-780-3745
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0500787QA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist