Provider Demographics
NPI:1063199776
Name:WILLIAMS, KELVIN TYRONE SR
Entity type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:TYRONE
Last Name:WILLIAMS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 HENRIETTA ST
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-3233
Mailing Address - Country:US
Mailing Address - Phone:912-322-4613
Mailing Address - Fax:
Practice Address - Street 1:551 HENRIETTA ST
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-3233
Practice Address - Country:US
Practice Address - Phone:912-322-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-04
Last Update Date:2023-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052191215172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver