Provider Demographics
NPI:1902965734
Name:BECERRIL, KENNETH MICHAEL (ACA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:BECERRIL
Suffix:
Gender:M
Credentials:ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5908 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1884
Mailing Address - Country:US
Mailing Address - Phone:951-779-1237
Mailing Address - Fax:951-779-1238
Practice Address - Street 1:5908 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1884
Practice Address - Country:US
Practice Address - Phone:951-779-1237
Practice Address - Fax:951-779-1238
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA3537237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64762ZOtherBLUE CARD
CABEL-45460OtherSECUREHORIZONS-PACIFICARE
CAZZZ64762ZOtherBLUE SHIELD OF CALIF.
CA611A63223OtherBLUE CROSS OF CALIF.
CAZZZ64762ZOtherBLUE SHIELD OF CALIF.