Provider Demographics
NPI:1063412740
Name:ENNIS, KEVIN USIF (AT,C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:USIF
Last Name:ENNIS
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 JANE WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-6009
Mailing Address - Country:US
Mailing Address - Phone:843-252-1142
Mailing Address - Fax:
Practice Address - Street 1:1076 RIBAUT RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5476
Practice Address - Country:US
Practice Address - Phone:843-521-1970
Practice Address - Fax:843-521-0908
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer