Provider Demographics
NPI:1417317207
Name:ALEX KVACH DC LLC
Entity Type:Organization
Organization Name:ALEX KVACH DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:KVACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-246-5808
Mailing Address - Street 1:1124 S COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-3929
Mailing Address - Country:US
Mailing Address - Phone:918-760-2539
Mailing Address - Fax:
Practice Address - Street 1:110 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7639
Practice Address - Country:US
Practice Address - Phone:918-246-5808
Practice Address - Fax:918-246-5809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-07
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4221111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201104490AMedicaid