Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TH0100X | Health Service |
NPI | 1558841684 |
---|---|
Provider Name | Mr. Kevin D Roberts |
First Address | St. Augustine, FL 32084 |
Second Address | St. Augustine, FL 32084 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2018 |
Last Update Date | 17/08/2018 |