Provider Demographics
NPI:1053314682
Name:WELLS, KENNETH A (ORT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:WELLS
Suffix:
Gender:M
Credentials:ORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3334 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:STE 400
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8405
Mailing Address - Country:US
Mailing Address - Phone:850-877-8174
Mailing Address - Fax:850-877-5636
Practice Address - Street 1:3334 CAPITAL MEDICAL BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4470
Practice Address - Country:US
Practice Address - Phone:850-877-8174
Practice Address - Fax:850-877-5636
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT44222Z00000X
GA000066222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA409058070AMedicaid