Provider Demographics
NPI:1124563812
Name:BEVIS, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BEVIS
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:PO BOX 650
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-0650
Mailing Address - Country:US
Mailing Address - Phone:808-769-5212
Mailing Address - Fax:808-769-5213
Practice Address - Street 1:81-6587 MAMALAHOA HWY
Practice Address - Street 2:SUITE C-301
Practice Address - City:KEALAKEKUA
Practice Address - State:HI
Practice Address - Zip Code:96750
Practice Address - Country:US
Practice Address - Phone:808-769-5212
Practice Address - Fax:808-769-5213
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10023405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional