Provider Demographics
NPI:1437989035
Name:CERVANTES, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CERVANTES
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 1:6722 SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-3904
Mailing Address - Country:US
Mailing Address - Phone:323-817-8200
Mailing Address - Fax:
Practice Address - Street 1:325 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3814
Practice Address - Country:US
Practice Address - Phone:310-648-3167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic