Healthcare Provider Details

I. General information

NPI: 1356807598
Provider Name (Legal Business Name): KATHRYN ARIEL KEVILLE L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E COTATI AVE STE E
COTATI CA
94931-7801
US

IV. Provider business mailing address

666 W SCHOOL ST
COTATI CA
94931-4164
US

V. Phone/Fax

Practice location:
  • Phone: 707-242-6812
  • Fax:
Mailing address:
  • Phone: 856-297-9084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC17507
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: