Provider Demographics
NPI:1831442961
Name:PACK, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 S HARBOR BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6928
Mailing Address - Country:US
Mailing Address - Phone:714-966-8650
Mailing Address - Fax:
Practice Address - Street 1:2124 MAIN ST
Practice Address - Street 2:STE 165
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-2405
Practice Address - Country:US
Practice Address - Phone:714-536-0077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program