Healthcare Provider Details

I. General information

NPI: 1134907173
Provider Name (Legal Business Name): GEVINAH HEALTHCARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 WASHINGTON RD
KENOSHA WI
53144-1604
US

IV. Provider business mailing address

9171 WILSHIRE BLVD STE 500
BEVERLY HILLS CA
90210-5536
US

V. Phone/Fax

Practice location:
  • Phone: 310-933-5688
  • Fax:
Mailing address:
  • Phone: 310-933-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL FARAH
Title or Position: OWNER
Credential:
Phone: 310-933-5688