Provider Demographics
NPI:1801418728
Name:FAISON, KEVIN (BA, QP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:FAISON
Suffix:
Gender:M
Credentials:BA, QP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 OLD COURTHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-5675
Mailing Address - Country:US
Mailing Address - Phone:252-814-0026
Mailing Address - Fax:
Practice Address - Street 1:3219 LANDMARK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-7688
Practice Address - Country:US
Practice Address - Phone:252-814-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC171M00000X, 172A00000X, 320800000X, 343900000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No374U00000XNursing Service Related ProvidersHome Health Aide