Provider Demographics
NPI:1164989067
Name:NGUYEN, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:NGUYEN
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 1:3303 HARBOR BLVD, COSTA MESA CA 92626
Mailing Address - Street 2:SUITE B8
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:714-786-6069
Mailing Address - Fax:
Practice Address - Street 1:3303 HARBOR BLVD, COSTA MESA CA 92626
Practice Address - Street 2:SUITE B8
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-786-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician