Provider Demographics
NPI:1609927656
Name:KETTERLING, SCOTT PHILIP (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:PHILIP
Last Name:KETTERLING
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 1:16659 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-4616
Mailing Address - Country:US
Mailing Address - Phone:952-898-0696
Mailing Address - Fax:651-385-5999
Practice Address - Street 1:217 PLUM ST
Practice Address - Street 2:SUITE 120
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2351
Practice Address - Country:US
Practice Address - Phone:651-385-5999
Practice Address - Fax:651-385-5999
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003487111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN126667500Medicaid
MN126667500Medicaid