Provider Demographics
NPI:1114315462
Name:CONDOS, KOLBY ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:KOLBY
Middle Name:ROBERT
Last Name:CONDOS
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 1:1200 S POKEGAMA AVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4291
Mailing Address - Country:US
Mailing Address - Phone:218-999-7006
Mailing Address - Fax:
Practice Address - Street 1:1200 S POKEGAMA AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4291
Practice Address - Country:US
Practice Address - Phone:218-999-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor