Provider Demographics
NPI:1740435080
Name:SPANGENBERG, KEVIN WAYNE (DPT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:SPANGENBERG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8180 MANITOBA ST
Mailing Address - Street 2:UNIT 145
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-8644
Mailing Address - Country:US
Mailing Address - Phone:804-691-3698
Mailing Address - Fax:
Practice Address - Street 1:6033 W CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-6410
Practice Address - Country:US
Practice Address - Phone:310-258-0684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35126225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist