Healthcare Provider Details

I. General information

NPI: 1386575629
Provider Name (Legal Business Name): KEVIN WONGVITAVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27200 TOURNEY RD
VALENCIA CA
91355-4990
US

IV. Provider business mailing address

27200 TOURNEY RD
VALENCIA CA
91355-4990
US

V. Phone/Fax

Practice location:
  • Phone: 661-222-9901
  • Fax:
Mailing address:
  • Phone: 661-220-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: