Provider Demographics
NPI:1477622405
Name:KRAUSE, KEVIN CARL
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:CARL
Last Name:KRAUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1375
Mailing Address - Street 2:
Mailing Address - City:BLACK CANYON CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85324-1375
Mailing Address - Country:US
Mailing Address - Phone:623-374-5658
Mailing Address - Fax:623-374-5233
Practice Address - Street 1:34501 SOUTH BLACK CANYON HIGHWAY
Practice Address - Street 2:SUITE #3
Practice Address - City:BLACK CANYON CITY
Practice Address - State:AZ
Practice Address - Zip Code:85324
Practice Address - Country:US
Practice Address - Phone:623-374-5658
Practice Address - Fax:623-374-5233
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7162111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZU78037Medicare UPIN
AZZ71649Medicare ID - Type Unspecified