Kendall Divante Leonard
Individual provider Active NPI Contractor · Glenwood, IL
NPI 1245864784 · NPPES record last updated Feb 24, 2020
Key facts
- NPI
- 1245864784
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Contractor 171W00000X
- License
- V00018705 (IL)
- Practice address
- 524 N Roberts Dr Apt 2B
Glenwood, IL 60425-2300 - Phone
- (708) 690-4333
- NPI assigned
- Feb 24, 2020
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| V00018705 | IL | MD | Contractor |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor |
171W00000X | V00018705 | IL | Yes |
Addresses
Primary practice location
524 N Roberts Dr Apt 2B
Glenwood, IL 60425-2300
Mailing address
3646 147TH PL Apt GN
Midlothian, IL 60445-3590
Phone (708) 690-4333
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 11295611761 | Medicaid | IL |
Other providers in Glenwood, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 24, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.