Provider Demographics
NPI:1477692143
Name:DAVIS, KENNETH A
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 OCEAN ST
Mailing Address - Street 2:USCG SECTOR JACKSONVILLE
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233
Mailing Address - Country:US
Mailing Address - Phone:904-564-7581
Mailing Address - Fax:904-564-7583
Practice Address - Street 1:400 SAND ISLAND PKWY
Practice Address - Street 2:CGC KUKUI (WLB-203)
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4326
Practice Address - Country:US
Practice Address - Phone:808-842-2860
Practice Address - Fax:808-842-2864
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians