Provider Demographics
NPI:1033804240
Name:PHYSIOC, KEVIN ANDREW
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:ANDREW
Last Name:PHYSIOC
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 1:334 MILL ST APT D
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-6727
Mailing Address - Country:US
Mailing Address - Phone:530-460-7656
Mailing Address - Fax:
Practice Address - Street 1:760 S AUBURN ST STE C2
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4318
Practice Address - Country:US
Practice Address - Phone:530-265-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion