Provider Demographics
NPI:1366631475
Name:WAXTER, KEVIN (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WAXTER
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 1:25 WHIPPOORWILL DR
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-9787
Mailing Address - Country:US
Mailing Address - Phone:570-424-9752
Mailing Address - Fax:570-424-9758
Practice Address - Street 1:2 ANALOMINK RD
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-9001
Practice Address - Country:US
Practice Address - Phone:570-424-9752
Practice Address - Fax:570-424-9758
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC 006735-L111N00000X
PAAJ 006735-L111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation