Provider Demographics
NPI:1770725053
Name:MAHAN, KEVIN DALE (LMT)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DALE
Last Name:MAHAN
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:PO BOX 8098
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-0098
Mailing Address - Country:US
Mailing Address - Phone:304-522-7553
Mailing Address - Fax:304-522-7838
Practice Address - Street 1:57 TOWNSHIP ROAD 1275
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-8030
Practice Address - Country:US
Practice Address - Phone:740-451-0307
Practice Address - Fax:740-451-0311
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator