Provider Demographics
NPI:1265462915
Name:MUNKSGARD, KEVIN JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JAMES
Last Name:MUNKSGARD
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 1:164 N 74TH ST APT 2086
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-8321
Mailing Address - Country:US
Mailing Address - Phone:480-854-4423
Mailing Address - Fax:
Practice Address - Street 1:753 S ALMA SCHOOL RD STE 3
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-1086
Practice Address - Country:US
Practice Address - Phone:480-827-2197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 29480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7681336Medicaid
CA7681336Medicaid
CAV03417Medicare UPIN