Provider Demographics
NPI:1689642506
Name:GRAVES, KENNETH WAYNE (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WAYNE
Last Name:GRAVES
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 RED POLL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78418
Mailing Address - Country:US
Mailing Address - Phone:361-937-1294
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL CORPUS CHRISTI
Practice Address - Street 2:10651 E STREET
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78419-5130
Practice Address - Country:US
Practice Address - Phone:361-961-3125
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman