Healthcare Provider Details

I. General information

NPI: 1639630437
Provider Name (Legal Business Name): MR. KEVIN CAMAGONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 WALL ST # 100
SEATTLE WA
98121-1431
US

IV. Provider business mailing address

222 WALL ST # 100
SEATTLE WA
98121-1431
US

V. Phone/Fax

Practice location:
  • Phone: 206-441-3043
  • Fax:
Mailing address:
  • Phone: 206-441-3043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG60806678
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: