Provider Demographics
NPI:1093226961
Name:BANKS, KEVIN MASON
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MASON
Last Name:BANKS
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 1:1813 BRUMLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-9018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1813 BRUMLEY RD
Practice Address - Street 2:
Practice Address - City:CHULUOTA
Practice Address - State:FL
Practice Address - Zip Code:32766-9018
Practice Address - Country:US
Practice Address - Phone:407-416-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL51521225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693226600Medicaid