Provider Demographics
NPI:1134893670
Name:WRATHALL, KEVIN SCOTT (LAC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SCOTT
Last Name:WRATHALL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-2005
Mailing Address - Country:US
Mailing Address - Phone:415-457-1549
Mailing Address - Fax:
Practice Address - Street 1:55 HILLSIDE DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:CA
Practice Address - Zip Code:94930-2005
Practice Address - Country:US
Practice Address - Phone:415-457-1549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13216171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist