Provider Demographics
NPI:1922746080
Name:STROUD, KEVIN ALEX
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALEX
Last Name:STROUD
Suffix:
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 1:4346 PASUTH LN
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288-1641
Mailing Address - Country:US
Mailing Address - Phone:678-592-1429
Mailing Address - Fax:
Practice Address - Street 1:4346 PASUTH LN
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288-1641
Practice Address - Country:US
Practice Address - Phone:678-592-1429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059707120347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle