Provider Demographics
NPI:1861031551
Name:HAGELIS, KEVIN JAMES
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:HAGELIS
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 1:10300 ARROW RTE APT 1107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7006
Mailing Address - Country:US
Mailing Address - Phone:909-967-9818
Mailing Address - Fax:
Practice Address - Street 1:9405 FAIRWAY VIEW PL
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0932
Practice Address - Country:US
Practice Address - Phone:909-481-7345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist