Provider Demographics
NPI:1477651685
Name:ODEGAARD, KENNETH WARREN II (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WARREN
Last Name:ODEGAARD
Suffix:II
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 1:21 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2219
Mailing Address - Country:US
Mailing Address - Phone:612-379-2344
Mailing Address - Fax:612-379-2751
Practice Address - Street 1:21 4TH ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2219
Practice Address - Country:US
Practice Address - Phone:612-379-2344
Practice Address - Fax:612-379-2751
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26583ODOtherMINNESOTA BLUE CROSS/BLUE