Healthcare Provider Details

I. General information

NPI: 1558607762
Provider Name (Legal Business Name): KEVIN GEORGE HARBOUR JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10221 COMPTON AVE
LOS ANGELES CA
90002-2802
US

IV. Provider business mailing address

10221 COMPTON AVE
LOS ANGELES CA
90002
US

V. Phone/Fax

Practice location:
  • Phone: 121-385-5510
  • Fax:
Mailing address:
  • Phone: 121-385-5510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: