=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588837629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELVIN CUNNINGHAM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2008
-----------------------------------------------------
Last Update Date | 04/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6055 E WASHINGTON BLVD STE 900
-----------------------------------------------------
City | COMMERCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90040-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-346-0960
-----------------------------------------------------
Fax | 323-346-0966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1060 GRAND AVE APT 6
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90804-8978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-786-3175
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------