Provider Demographics
NPI:1376244004
Name:GOLDEN, KEVIN LEWIS
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEWIS
Last Name:GOLDEN
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 1:4306 COTTONTAIL LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5129
Mailing Address - Country:US
Mailing Address - Phone:725-260-6905
Mailing Address - Fax:
Practice Address - Street 1:4250 E BONANZA RD STE 17
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-6105
Practice Address - Country:US
Practice Address - Phone:702-331-4277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner