Provider Demographics
NPI:1326474834
Name:KRUG, KIMBERLY ROACH
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ROACH
Last Name:KRUG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:ROACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:17 FAIRTY DR
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-6240
Mailing Address - Country:US
Mailing Address - Phone:203-650-7507
Mailing Address - Fax:
Practice Address - Street 1:17 FAIRTY DR
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-6240
Practice Address - Country:US
Practice Address - Phone:203-650-7507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001212111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor