Provider Demographics
NPI:1518759984
Name:SMITH, KENNETH R
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:SMITH
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 1:643 CHAMPIONS DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8806
Mailing Address - Country:US
Mailing Address - Phone:315-706-8337
Mailing Address - Fax:
Practice Address - Street 1:643 CHAMPIONS DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8806
Practice Address - Country:US
Practice Address - Phone:315-706-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle