Provider Demographics
NPI:1386014611
Name:FARRELL, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FARRELL
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 1:12490 TESSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2702
Mailing Address - Country:US
Mailing Address - Phone:314-849-6700
Mailing Address - Fax:314-849-6706
Practice Address - Street 1:12490 TESSON FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2702
Practice Address - Country:US
Practice Address - Phone:314-849-6700
Practice Address - Fax:314-849-6706
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2015021244237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2015021244OtherHEARING AID DISPENSER LICENSE