Provider Demographics
NPI:1285640300
Name:DEFRIES, KEVIN JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:DEFRIES
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 1:5529 W STATE ROAD 10
Mailing Address - Street 2:PO 238
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8799
Mailing Address - Country:US
Mailing Address - Phone:219-987-7333
Mailing Address - Fax:219-987-7749
Practice Address - Street 1:5529 W STATE ROAD 10
Practice Address - Street 2:PO 238
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8799
Practice Address - Country:US
Practice Address - Phone:219-987-7333
Practice Address - Fax:219-987-7749
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000203794OtherANTHEM
IN000000203794OtherANTHEM
IN391770Medicare ID - Type UnspecifiedMEDICARE