Healthcare Provider Details

I. General information

NPI: 1790605095
Provider Name (Legal Business Name): KEAVEN SA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 LAUREL ST
SAN DIEGO CA
92101-1634
US

IV. Provider business mailing address

545 LAUREL ST
SAN DIEGO CA
92101-1634
US

V. Phone/Fax

Practice location:
  • Phone: 619-233-4399
  • Fax: 619-233-0453
Mailing address:
  • Phone: 619-233-4399
  • Fax: 619-233-0453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-UKWGEO
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: