Provider Demographics
NPI:1275680175
Name:TEAGLE, KEVIN C (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:TEAGLE
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 1:1829 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5701
Mailing Address - Country:US
Mailing Address - Phone:541-474-2225
Mailing Address - Fax:541-474-2229
Practice Address - Street 1:1829 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5701
Practice Address - Country:US
Practice Address - Phone:541-474-2225
Practice Address - Fax:541-474-2229
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3232111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3232OtherSTATE LICENSE #
OR93-1325306OtherTAX ID #
OR111323Medicare ID - Type Unspecified