Provider Demographics
NPI:1568290641
Name:TALAID, KENN NICHOLAS UNGAB
Entity type:Individual
Prefix:
First Name:KENN NICHOLAS
Middle Name:UNGAB
Last Name:TALAID
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1922 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-1457
Mailing Address - Country:US
Mailing Address - Phone:209-594-7259
Mailing Address - Fax:
Practice Address - Street 1:650 S BASCOM AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2601
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-642-6052
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41801167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician