Provider Demographics
NPI:1891248456
Name:STGERMAIN, KEVIN RAY JR
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RAY
Last Name:STGERMAIN
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 1:1810 S 285TH PL BLDG BE
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3026
Mailing Address - Country:US
Mailing Address - Phone:253-686-3617
Mailing Address - Fax:
Practice Address - Street 1:612 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-2213
Practice Address - Country:US
Practice Address - Phone:206-244-1466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-01
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60668279225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist