Provider Demographics
NPI:1386451391
Name:MINGO, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MINGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15384 CRUSE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3227
Mailing Address - Country:US
Mailing Address - Phone:313-629-6505
Mailing Address - Fax:
Practice Address - Street 1:15384 CRUSE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3227
Practice Address - Country:US
Practice Address - Phone:313-629-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider