Provider Demographics
NPI:1285218677
Name:BENNETT, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BENNETT
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 1:20695 S WESTERN AVE STE 132
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-1834
Mailing Address - Country:US
Mailing Address - Phone:424-271-7414
Mailing Address - Fax:
Practice Address - Street 1:19503 GALWAY AVE
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-1923
Practice Address - Country:US
Practice Address - Phone:310-817-5267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator