Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003480468 |
---|---|
Provider Name | Kevin Jacob Winston |
First Address | Culver City, CA 90232-6824 |
Second Address | Culver City, CA 90232-6824 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2021 |
Last Update Date | 19/05/2021 |