Provider Demographics
NPI:1710717947
Name:LY, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 1/2 N AVENUE 56
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90042-4113
Mailing Address - Country:US
Mailing Address - Phone:714-316-4249
Mailing Address - Fax:
Practice Address - Street 1:3350 W 1ST ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-6000
Practice Address - Country:US
Practice Address - Phone:213-289-3578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker