Provider Demographics
NPI:1376007849
Name:SPICER, KEVIN M (LP, COA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:SPICER
Suffix:
Gender:M
Credentials:LP, COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:OH
Mailing Address - Zip Code:44612-8512
Mailing Address - Country:US
Mailing Address - Phone:330-904-9156
Mailing Address - Fax:
Practice Address - Street 1:1830 RIDGE RD NW
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:OH
Practice Address - Zip Code:44612-8512
Practice Address - Country:US
Practice Address - Phone:330-595-1010
Practice Address - Fax:330-595-1051
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COA00304225000000X
OHLP.00116224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter