Provider Demographics
NPI:1497815575
Name:KOENKE, KYLE ANDREW (DC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDREW
Last Name:KOENKE
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 1:1066 N POWER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-5709
Mailing Address - Country:US
Mailing Address - Phone:480-830-7288
Mailing Address - Fax:480-985-7255
Practice Address - Street 1:1066 N POWER RD STE 104
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5709
Practice Address - Country:US
Practice Address - Phone:480-830-7288
Practice Address - Fax:480-985-7255
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7157111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRRP00086254OtherRRBCBS
AZAZ0943870OtherBCBS
AZU97070Medicare UPIN
AZRRP00086254OtherRRBCBS