Provider Demographics
NPI:1255061107
Name:HINES, KEVIN LEE
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEE
Last Name:HINES
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 1:8338 HIGHWAY 65 NE STE E
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-1365
Mailing Address - Country:US
Mailing Address - Phone:763-755-9500
Mailing Address - Fax:763-755-9510
Practice Address - Street 1:8338 HIGHWAY 65 NE STE E
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-1365
Practice Address - Country:US
Practice Address - Phone:763-755-9500
Practice Address - Fax:763-755-9510
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1001335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier