Provider Demographics
NPI:1043274087
Name:GANSERT, KEVIN KARL (DC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:KARL
Last Name:GANSERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 N EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-3223
Mailing Address - Country:US
Mailing Address - Phone:909-460-1100
Mailing Address - Fax:909-460-0433
Practice Address - Street 1:601 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3223
Practice Address - Country:US
Practice Address - Phone:626-852-2268
Practice Address - Fax:909-687-2622
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25567111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25567Medicare ID - Type UnspecifiedCHIROPRACTIC