Provider Demographics
NPI:1548746688
Name:GLEATON, KEVIN MAURICE
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MAURICE
Last Name:GLEATON
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 1:9209 SHEFFIELD HUNT CT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1891
Mailing Address - Country:US
Mailing Address - Phone:571-352-0654
Mailing Address - Fax:
Practice Address - Street 1:9209 SHEFFIELD HUNT COURT
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079
Practice Address - Country:US
Practice Address - Phone:571-352-0654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA66143244172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver