Provider Demographics
NPI:1922601392
Name:SHELTON, KEVIN WAYNE (LMT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:SHELTON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4073 N FRUIT AVE APT 117
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-2136
Mailing Address - Country:US
Mailing Address - Phone:559-720-9493
Mailing Address - Fax:
Practice Address - Street 1:4073 N FRUIT AVE APT 117
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-2136
Practice Address - Country:US
Practice Address - Phone:559-720-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78975225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist