Provider Demographics
NPI:1699120410
Name:DR KENNEITH DURDEN OUTREACH
Entity type:Organization
Organization Name:DR KENNEITH DURDEN OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:DURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-909-2442
Mailing Address - Street 1:41 MOONLIGHT TRL
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-3321
Mailing Address - Country:US
Mailing Address - Phone:404-909-2442
Mailing Address - Fax:
Practice Address - Street 1:41 MOONLIGHT TRL
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-3321
Practice Address - Country:US
Practice Address - Phone:404-909-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA803411511BMedicaid