Provider Demographics
NPI:1700361383
Name:VILLAREALE, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:VILLAREALE
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 1:2210 MIAMI ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46613-2939
Mailing Address - Country:US
Mailing Address - Phone:716-536-0875
Mailing Address - Fax:
Practice Address - Street 1:9811 W CHARLESTON BLVD # 2-641
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:855-864-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG