Provider Demographics
NPI:1053444166
Name:KENNETH W VAN WYK
Entity Type:Organization
Organization Name:KENNETH W VAN WYK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:VAN WYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-274-6104
Mailing Address - Street 1:6900 UNIVERSITY AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1505
Mailing Address - Country:US
Mailing Address - Phone:515-274-6104
Mailing Address - Fax:515-255-3355
Practice Address - Street 1:6900 UNIVERSITY AVE STE 108
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-1505
Practice Address - Country:US
Practice Address - Phone:515-274-6104
Practice Address - Fax:515-255-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04783Medicare ID - Type Unspecified