Healthcare Provider Details

I. General information

NPI: 1659294882
Provider Name (Legal Business Name): KENNETH PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 KINGSMOOR DR
SIMPSONVILLE SC
29681-3500
US

IV. Provider business mailing address

527 KINGSMOOR DR
SIMPSONVILLE SC
29681-3500
US

V. Phone/Fax

Practice location:
  • Phone: 619-873-7701
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number269733
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: