Provider Demographics
NPI:1629013297
Name:OUDENHOVEN, KEITH J (DC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:OUDENHOVEN
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 1:3020 E COLLEGE AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-3279
Mailing Address - Country:US
Mailing Address - Phone:920-738-9996
Mailing Address - Fax:920-738-0603
Practice Address - Street 1:3020 E COLLEGE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-3279
Practice Address - Country:US
Practice Address - Phone:920-738-9996
Practice Address - Fax:920-738-0603
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2420-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38894800Medicaid
WIP00132309OtherNETWORK HEALTH PLAN
WI38894800Medicaid