Healthcare Provider Details

I. General information

NPI: 1093404865
Provider Name (Legal Business Name): MR. KENNY RAY WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 05/05/2023
Certification Date: 05/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10320 N AIRPORT RD
CLINTON OK
73601-7530
US

IV. Provider business mailing address

PO BOX 175
CLINTON OK
73601-0175
US

V. Phone/Fax

Practice location:
  • Phone: 580-331-2370
  • Fax: 405-422-8282
Mailing address:
  • Phone: 580-331-2370
  • Fax: 405-422-8282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: