Provider Demographics
NPI:1831856210
Name:HAZEL, KEVIN DARYL
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DARYL
Last Name:HAZEL
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 1:724 DENNIS AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6215
Mailing Address - Country:US
Mailing Address - Phone:619-762-0610
Mailing Address - Fax:
Practice Address - Street 1:15373 INNOVATION DR STE 220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-3425
Practice Address - Country:US
Practice Address - Phone:858-592-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant