Provider Demographics
NPI:1518971050
Name:PEDERSON, KENT (DC)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:PEDERSON
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 1:11111 N SCOTTSDALE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-6701
Mailing Address - Country:US
Mailing Address - Phone:480-609-1080
Mailing Address - Fax:480-951-7581
Practice Address - Street 1:11111 N SCOTTSDALE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6701
Practice Address - Country:US
Practice Address - Phone:480-609-1080
Practice Address - Fax:480-951-7581
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0936750OtherBCBS OF AZ PROVIDER ID#
AZU20984Medicare UPIN
AZ71546Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER