Provider Demographics
NPI:1881573194
Name:RUST, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RUST
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 1:3418 BLACK HAWK RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-2327
Mailing Address - Country:US
Mailing Address - Phone:707-479-3877
Mailing Address - Fax:
Practice Address - Street 1:1777 BOTELHO DR
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-5086
Practice Address - Country:US
Practice Address - Phone:925-934-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist