Provider Demographics
NPI:1568568251
Name:ANDERSEN, KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:ANDERSEN
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 1:15220 SE 272ND ST STE D
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4241
Mailing Address - Country:US
Mailing Address - Phone:253-631-7933
Mailing Address - Fax:253-631-4786
Practice Address - Street 1:15220 SE 272ND ST STE D
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-4241
Practice Address - Country:US
Practice Address - Phone:253-631-7933
Practice Address - Fax:253-631-4786
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003327111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB01674Medicare UPIN