Provider Demographics
NPI:1538505201
Name:KAGARISE, LAURA COLLEEN (DC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:COLLEEN
Last Name:KAGARISE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53125 NADINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-5118
Mailing Address - Country:US
Mailing Address - Phone:574-261-2067
Mailing Address - Fax:
Practice Address - Street 1:413 W MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-5599
Practice Address - Country:US
Practice Address - Phone:574-256-1008
Practice Address - Fax:574-256-9088
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002698A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor