Basic Information
| Provider Information | |||||||||
| NPI: | 1942835434 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWERS | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 485 S 350 E # 32-1 | ||||||||
| Address2: | |||||||||
| City: | ROOSEVELT | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840663344 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | ROUTE 264 MP 388 | ||||||||
| Address2: | |||||||||
| City: | POLACCA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287376000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2020 | ||||||||
| LastUpdateDate: | 03/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 9008535-3102 | AZ | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 020529 | 05 | AZ | MEDICAID |