Provider Demographics
NPI:1265629240
Name:KENN E IVERSON DC P C
Entity Type:Organization
Organization Name:KENN E IVERSON DC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-252-2424
Mailing Address - Street 1:312 2ND AVE SW STE 101
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-4177
Mailing Address - Country:US
Mailing Address - Phone:701-252-2424
Mailing Address - Fax:701-252-3205
Practice Address - Street 1:312 2ND AVE SW STE 101
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4177
Practice Address - Country:US
Practice Address - Phone:701-252-2424
Practice Address - Fax:701-252-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND733111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND13530Medicaid
ND6577-001OtherBLUE CROSS
ND13530Medicaid
ND6577-001OtherBLUE CROSS