1265606081 NPI number — KENNETH STEVENS MD INC A MEDICAL CORPORATION

Table of content: (NPI 1265606081)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265606081 NPI number — KENNETH STEVENS MD INC A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH STEVENS MD INC A MEDICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265606081
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3268 WATERSTONE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSON
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89044-1867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-378-8514
Provider Business Mailing Address Fax Number:
805-540-3344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3268 WATERSTONE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89044-1867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-378-8514
Provider Business Practice Location Address Fax Number:
805-540-3344
Provider Enumeration Date:
04/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
STEVENS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
815-378-8514

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 05D1083425 . This is a "CLIA CERTIFICATE OF WAIVER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ53712Y . This is a "BLUE SHIELD PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: C3092297 . This is a "DEPT OF CORPORATIONS NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 37534 . This is a "MEDICAL BOARD FICTITIOUS NAME PERMIT NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 106286 . This is a "CITY OF SAN LUIS OBISPO BUSINESS LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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