Kevin G Wynne, D.C.
Individual provider Active NPI Chiropractor · Lake Mary, FL
NPI 1710970686 · NPPES record last updated Oct 7, 2011
Key facts
- NPI
- 1710970686
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Chiropractor 111N00000X
- License
- CH7382 (FL)
- Practice address
- 365 Waymont CT
Suite 101
Lake Mary, FL 32746-3552 - Phone
- (407) 321-9191
- Fax
- (407) 321-9899
- NPI assigned
- Aug 25, 2005
- Reactivated
- Apr 7, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| CH7382 | FL | MD | Chiropractor |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor | 111N00000X | CH7382 | FL | Yes |
Addresses
Primary practice location
365 Waymont CT
Suite 101
Lake Mary, FL 32746-3552
Mailing address
365 Waymont CT
Suite 101
Lake Mary, FL 32746-3552
Phone (407) 321-9191
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 55683 | Other | FL | BCBS |
| 381358400 | Medicaid | FL |
Other providers in Lake Mary, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 7, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.