Provider Demographics
NPI:1275886657
Name:ALVERSON, KENNETH JAMES (COTA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JAMES
Last Name:ALVERSON
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 ASHLEY DANIELLE DR
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:SC
Mailing Address - Zip Code:29334-8960
Mailing Address - Country:US
Mailing Address - Phone:864-245-7337
Mailing Address - Fax:
Practice Address - Street 1:273 ASHLEY DANIELLE DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:SC
Practice Address - Zip Code:29334-8960
Practice Address - Country:US
Practice Address - Phone:864-245-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1574171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor