Provider Demographics
NPI:1518241413
Name:THERIAULT, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:THERIAULT
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 1:120 W MINOT RD
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ME
Mailing Address - Zip Code:04258-5420
Mailing Address - Country:US
Mailing Address - Phone:207-745-7835
Mailing Address - Fax:
Practice Address - Street 1:120 W MINOT RD
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ME
Practice Address - Zip Code:04258-5420
Practice Address - Country:US
Practice Address - Phone:207-745-7835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME8297140172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver