Provider Demographics
NPI:1699461350
Name:GENTRY, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GENTRY
Suffix:
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 1:5869 US HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31050-2562
Mailing Address - Country:US
Mailing Address - Phone:770-946-2453
Mailing Address - Fax:478-294-1866
Practice Address - Street 1:3640 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3676
Practice Address - Country:US
Practice Address - Phone:770-946-2453
Practice Address - Fax:478-294-1866
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician