Provider Demographics
NPI:1710970686
Name:WYNNE, KEVIN G (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:G
Last Name:WYNNE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 WAYMONT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3552
Mailing Address - Country:US
Mailing Address - Phone:407-321-9191
Mailing Address - Fax:407-321-9899
Practice Address - Street 1:365 WAYMONT CT
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3552
Practice Address - Country:US
Practice Address - Phone:407-321-9191
Practice Address - Fax:407-321-9899
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2011-10-07
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
FLCH7382111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55683OtherBCBS
FL381358400Medicaid
FL55683Medicare ID - Type Unspecified
FL381358400Medicaid