Provider Demographics
NPI:1568176147
Name:GRANT, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:GRANT
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 1:1152 E 1ST ST APT 108
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5630
Mailing Address - Country:US
Mailing Address - Phone:215-578-8596
Mailing Address - Fax:
Practice Address - Street 1:1152 E 1ST ST APT 108
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-5630
Practice Address - Country:US
Practice Address - Phone:215-578-8596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program