Provider Demographics
NPI:1669615787
Name:WILIAMS, KEVIN K
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:K
Last Name:WILIAMS
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 1:3921 ALBERTA ST
Mailing Address - Street 2:3921 ALBERTA STREET
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4519
Mailing Address - Country:US
Mailing Address - Phone:314-452-7352
Mailing Address - Fax:
Practice Address - Street 1:3921 ALBERTA ST
Practice Address - Street 2:3921 ALBERTA STREET
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-4519
Practice Address - Country:US
Practice Address - Phone:314-452-7352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13-4255793251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health