Healthcare Provider Details

I. General information

NPI: 1801418728
Provider Name (Legal Business Name): KEVIN FAISON BA, QP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 LANDMARK ST
GREENVILLE NC
27834-7688
US

IV. Provider business mailing address

2203 OLD COURTHOUSE DR
GREENVILLE NC
27858-5675
US

V. Phone/Fax

Practice location:
  • Phone: 252-814-0026
  • Fax:
Mailing address:
  • Phone: 252-814-0026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: