Basic Information
| Provider Information | |||||||||
| NPI: | 1730200940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5747 LAUREL CANYON BLVD | ||||||||
| Address2: | 33 | ||||||||
| City: | VALLEY VILLAGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916071217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187692816 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2055 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911031324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267986793 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.