Provider Demographics
NPI:1902405350
Name:VILLANUEVA, KEVIN LOZARES (PTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LOZARES
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7155 CALSTON PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-5958
Mailing Address - Country:US
Mailing Address - Phone:858-335-6957
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3536
Practice Address - Country:US
Practice Address - Phone:619-237-9027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50796225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant