Provider Demographics
NPI:1730619131
Name:BOIVIN, KEVIN EMMETT (MT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:EMMETT
Last Name:BOIVIN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14950 W MOUNTAIN VIEW BLVD APT 7205
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-4722
Mailing Address - Country:US
Mailing Address - Phone:219-688-4179
Mailing Address - Fax:
Practice Address - Street 1:14950 W MOUNTAIN VIEW BLVD APT 7205
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4722
Practice Address - Country:US
Practice Address - Phone:219-688-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA.60745513225700000X
AZMT-28141225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1972655132OtherREGENCE