Healthcare Provider Details

I. General information

NPI: 1902716152
Provider Name (Legal Business Name): DEVON KISHKETON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10936 DALE AVE
STANTON CA
90680-2724
US

IV. Provider business mailing address

10936 DALE AVE
STANTON CA
90680-2724
US

V. Phone/Fax

Practice location:
  • Phone: 714-952-4032
  • Fax: 714-952-4065
Mailing address:
  • Phone: 714-950-4032
  • Fax: 714-952-4065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: