Provider Demographics
NPI:1720851769
Name:EDWARDS, KENNETH LEE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEE
Last Name:EDWARDS
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 1:4073 LEDAN EXT
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-2024
Mailing Address - Country:US
Mailing Address - Phone:706-297-7292
Mailing Address - Fax:706-297-7317
Practice Address - Street 1:3886 GA HWY 17
Practice Address - Street 2:
Practice Address - City:EASTANOLLEE
Practice Address - State:GA
Practice Address - Zip Code:30538
Practice Address - Country:US
Practice Address - Phone:706-297-7292
Practice Address - Fax:706-297-7317
Is Sole Proprietor?:No
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1847156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician