MEDICARE: KEVIN DURAN SUDRC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA

General Provider Information

NPI Number	:	1649854860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN DURAN SUDRC

Provider Business Mailing Address
First Line	:	4363 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6236
Country	:	US
Telephone Number	:	323-378-2009
Fax Number	:	213-395-9592

Provider Business Practice Location Address
First Line	:	4363 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6236
Country	:	US
Telephone Number	:	323-378-2009
Fax Number	:	213-395-9592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2021
Last Update Date	:	05/12/2021

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