Provider Demographics
NPI:1164574752
Name:KENT CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:KENT CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-696-9110
Mailing Address - Street 1:245 PRIOR AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-5163
Mailing Address - Country:US
Mailing Address - Phone:651-696-9110
Mailing Address - Fax:888-503-7553
Practice Address - Street 1:245 PRIOR AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-5163
Practice Address - Country:US
Practice Address - Phone:651-696-9110
Practice Address - Fax:888-503-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2722261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN273528800Medicaid