Provider Demographics
NPI:1871870022
Name:CONKLIN, KEN SAMUEL (IDC)
Entity type:Individual
Prefix:MR
First Name:KEN
Middle Name:SAMUEL
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34101 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5291
Mailing Address - Country:US
Mailing Address - Phone:910-450-6324
Mailing Address - Fax:
Practice Address - Street 1:PSC BOX 20073
Practice Address - Street 2:CAMP LEJEUNE, NC
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:28542-0073
Practice Address - Country:US
Practice Address - Phone:808-721-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman