Provider Demographics
NPI:1508290529
Name:PROCTOR, KEVIN SAMUEL (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SAMUEL
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:730 CHICAGO DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3004
Mailing Address - Country:US
Mailing Address - Phone:616-796-6781
Mailing Address - Fax:
Practice Address - Street 1:350 N MAIN ST
Practice Address - Street 2:SUITE 180
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1370
Practice Address - Country:US
Practice Address - Phone:734-475-9925
Practice Address - Fax:734-475-9927
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010164602251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic