Healthcare Provider Details

I. General information

NPI: 1356271142
Provider Name (Legal Business Name): KEVIN DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W CALIFORNIA BLVD STE 228
PASADENA CA
91105-3033
US

IV. Provider business mailing address

5820 DAVID AVE APT 6
LOS ANGELES CA
90034-2252
US

V. Phone/Fax

Practice location:
  • Phone: 909-206-2443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberL10141
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: