Provider Demographics
NPI:1871643973
Name:BOTTORFF, KEVIN JOSEPH (LPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:BOTTORFF
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3250 WINDSOX CT
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-2685
Mailing Address - Country:US
Mailing Address - Phone:559-662-1055
Mailing Address - Fax:
Practice Address - Street 1:480 E 13TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-6214
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29632167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician