Provider Demographics
NPI:1154743391
Name:KENSHO WELLNESS GROUP, LLC.
Entity type:Organization
Organization Name:KENSHO WELLNESS GROUP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDD
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-990-0340
Mailing Address - Street 1:3550 POWERLINE RD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5919
Mailing Address - Country:US
Mailing Address - Phone:855-972-8674
Mailing Address - Fax:
Practice Address - Street 1:3550 POWERLINE RD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-5919
Practice Address - Country:US
Practice Address - Phone:855-972-8674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty