Provider Demographics
NPI:1881095024
Name:SHELTON, KENNETH II
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SHELTON
Suffix:II
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 1:122 SIKKEMA LN
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29070-7227
Mailing Address - Country:US
Mailing Address - Phone:803-767-8634
Mailing Address - Fax:
Practice Address - Street 1:122 SIKKEMA LN
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:SC
Practice Address - Zip Code:29070-7227
Practice Address - Country:US
Practice Address - Phone:803-767-8634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer