Healthcare Provider Details

I. General information

NPI: 1477692143
Provider Name (Legal Business Name): KENNETH A. DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SAND ISLAND PKWY CGC KUKUI (WLB-203)
HONOLULU HI
96819-4326
US

IV. Provider business mailing address

4200 OCEAN ST USCG SECTOR JACKSONVILLE
ATLANTIC BEACH FL
32233
US

V. Phone/Fax

Practice location:
  • Phone: 808-842-2860
  • Fax: 808-842-2864
Mailing address:
  • Phone: 904-564-7581
  • Fax: 904-564-7583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: