Provider Demographics
NPI:1558065961
Name:TEAGUE, KEVIN CHARLES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:TEAGUE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-0978
Mailing Address - Country:US
Mailing Address - Phone:559-905-5778
Mailing Address - Fax:
Practice Address - Street 1:6254 66TH AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2733
Practice Address - Country:US
Practice Address - Phone:916-392-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT302279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist