Healthcare Provider Details

I. General information

NPI: 1407223639
Provider Name (Legal Business Name): KENNETH WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 09/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 26TH ST W
BRADENTON FL
34207-3012
US

IV. Provider business mailing address

PO BOX 997
PALMETTO FL
34220-0997
US

V. Phone/Fax

Practice location:
  • Phone: 941-708-8500
  • Fax: 941-708-8503
Mailing address:
  • Phone: 941-776-4000
  • Fax: 941-776-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: