Provider Demographics
NPI:1497873905
Name:CRIPE, KELLY JON (DC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JON
Last Name:CRIPE
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:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-1638
Mailing Address - Country:US
Mailing Address - Phone:763-295-2262
Mailing Address - Fax:763-295-6282
Practice Address - Street 1:212 CEDAR ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-295-2262
Practice Address - Fax:763-295-6282
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN422L1MOOtherBCBS PIN
MN4278429-00OtherMN HEALTH CARE PROGRAMS
MN422L0MOOtherBCBS GIN
MN641442OtherCCMI
MN4278429-00OtherMN HEALTH CARE PROGRAMS
MNU88667Medicare UPIN