Provider Demographics
NPI:1508579939
Name:SANDERS, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SANDERS
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:PO BOX 649
Mailing Address - Street 2:
Mailing Address - City:FORT DEFIANCE
Mailing Address - State:AZ
Mailing Address - Zip Code:86504-0649
Mailing Address - Country:US
Mailing Address - Phone:928-729-8000
Mailing Address - Fax:
Practice Address - Street 1:CORNER OF RTE N12 AND N7
Practice Address - Street 2:
Practice Address - City:FT. DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504-0649
Practice Address - Country:US
Practice Address - Phone:928-729-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRCP000573342278C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2278C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedCritical CareGroup - Single Specialty