Provider Demographics
NPI:1831867621
Name:FARES, KELVIN EDWARD
Entity type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:EDWARD
Last Name:FARES
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 1:4955 VAN NUYS BLVD STE 615
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1839
Mailing Address - Country:US
Mailing Address - Phone:818-905-2222
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD STE 615
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1839
Practice Address - Country:US
Practice Address - Phone:818-905-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant