Provider Demographics
NPI:1699310466
Name:GREEN, KENNETH LEROY JR
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LEROY
Last Name:GREEN
Suffix:JR
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 1:1101 HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:HOWEY IN THE HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34737-3706
Mailing Address - Country:US
Mailing Address - Phone:352-516-1347
Mailing Address - Fax:813-354-2497
Practice Address - Street 1:7939 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7931
Practice Address - Country:US
Practice Address - Phone:352-257-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies