Provider Demographics
NPI:1730797218
Name:BUTLER, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BUTLER
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 1:10912 WAHINE DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9446
Mailing Address - Country:US
Mailing Address - Phone:904-554-0912
Mailing Address - Fax:
Practice Address - Street 1:10912 WAHINE DR S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-9446
Practice Address - Country:US
Practice Address - Phone:904-554-0912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health