Provider Demographics
NPI:1689424012
Name:POLLARD, KEVIN LEE JR
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:POLLARD
Suffix:JR
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 77
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-0077
Mailing Address - Country:US
Mailing Address - Phone:631-408-2213
Mailing Address - Fax:
Practice Address - Street 1:1116 WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:HOLTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11742-1114
Practice Address - Country:US
Practice Address - Phone:631-408-2213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY555559628172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver