Healthcare Provider Details

I. General information

NPI: 1619614807
Provider Name (Legal Business Name): MR. KEVIN EUGENE PUCKETT JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2022
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 SIERRA VISTA AVE
RIVERSIDE CA
92505-3113
US

IV. Provider business mailing address

3380 LA SIERRA AVE
RIVERSIDE CA
92503-5271
US

V. Phone/Fax

Practice location:
  • Phone: 951-299-7645
  • Fax:
Mailing address:
  • Phone: 951-299-7645
  • Fax: 951-299-7510

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: