Provider Demographics
NPI:1801287859
Name:GAVIN, KENNETH (CO, MED)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GAVIN
Suffix:
Gender:M
Credentials:CO, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 N CIRCLE DR
Mailing Address - Street 2:STE. 110
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1177
Mailing Address - Country:US
Mailing Address - Phone:719-776-4840
Mailing Address - Fax:719-776-4845
Practice Address - Street 1:3030 N CIRCLE DR
Practice Address - Street 2:STE. 110
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1177
Practice Address - Country:US
Practice Address - Phone:719-776-4840
Practice Address - Fax:719-776-4845
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840405257OtherTIN 840405257