=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760308308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN FARISON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2026
-----------------------------------------------------
Last Update Date | 06/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1365 STOCKTON AVE
-----------------------------------------------------
City | KETTERING
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-689-3980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1365 STOCKTON AVE
-----------------------------------------------------
City | KETTERING
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45409-1849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-689-3980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------