Healthcare Provider Details

I. General information

NPI: 1316884414
Provider Name (Legal Business Name): KEVIN JEFFREY PAGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 PENNSYLVANIA AVE STE B
FAIRFIELD CA
94533-3549
US

IV. Provider business mailing address

15638 CRIMSON TOPAZ
SAN ANTONIO TX
78253-4050
US

V. Phone/Fax

Practice location:
  • Phone: 707-425-2187
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: