Provider Demographics
NPI:1053196485
Name:ORTIZ, KENDAL EMANUEL
Entity type:Individual
Prefix:DR
First Name:KENDAL
Middle Name:EMANUEL
Last Name:ORTIZ
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 1:902 LIDDELL ST
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8314
Mailing Address - Country:US
Mailing Address - Phone:762-209-1204
Mailing Address - Fax:
Practice Address - Street 1:4700 TENNESSEE AVE # 58
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37409-1837
Practice Address - Country:US
Practice Address - Phone:423-892-8803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist