MEDICARE: KENNETH A. DAVIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1477692143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH A. DAVIS

Provider Business Mailing Address
First Line	:	4200 OCEAN ST
Second Line	:	USCG SECTOR JACKSONVILLE
City	:	ATLANTIC BEACH
State	:	FL
Zip	:	32233
Country	:	US
Telephone Number	:	904-564-7581
Fax Number	:	904-564-7583

Provider Business Practice Location Address
First Line	:	400 SAND ISLAND PKWY
Second Line	:	CGC KUKUI (WLB-203)
City	:	HONOLULU
State	:	HI
Zip	:	96819-4326
Country	:	US
Telephone Number	:	808-842-2860
Fax Number	:	808-842-2864

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	11/02/2012

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