Provider Demographics
NPI:1104008663
Name:MIKALAITIS, KEVIN RUSSELL
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:RUSSELL
Last Name:MIKALAITIS
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 1:1318 VIVIAN ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3217
Mailing Address - Country:US
Mailing Address - Phone:303-776-0882
Mailing Address - Fax:303-776-1053
Practice Address - Street 1:1318 VIVIAN ST
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3217
Practice Address - Country:US
Practice Address - Phone:303-776-0882
Practice Address - Fax:303-776-1053
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR-6064111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor