Provider Demographics
NPI:1619567872
Name:WILSON, KENNETH R SR
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:WILSON
Suffix:SR
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 1:2081 CHAFFEE RD S LOT 119
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-1887
Mailing Address - Country:US
Mailing Address - Phone:904-834-9093
Mailing Address - Fax:
Practice Address - Street 1:2081 CHAFFEE RD S LOT 119
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-1887
Practice Address - Country:US
Practice Address - Phone:904-834-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies