Basic Information
Provider Information
NPI: 1033556238
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SEALS
FirstName: KEVIN
MiddleName: FREDERICK
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2028 DELAWARE AVE
Address2:  
City: SANTA MONICA
State: CA
PostalCode: 904044871
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 1000 W CARSON ST # 400
Address2:  
City: TORRANCE
State: CA
PostalCode: 905022004
CountryCode: US
TelephoneNumber: 3102222401
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/28/2013
LastUpdateDate: 05/28/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X  Y Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


Home