Provider Demographics
NPI:1205324282
Name:GARRISON, KEVIN S
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
Last Name:GARRISON
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 1:17184 NE 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3102
Mailing Address - Country:US
Mailing Address - Phone:305-949-1888
Mailing Address - Fax:305-949-5546
Practice Address - Street 1:17184 NE 19TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3102
Practice Address - Country:US
Practice Address - Phone:305-949-1888
Practice Address - Fax:305-949-5546
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL028841100Medicaid