Provider Demographics
NPI:1639239650
Name:SMALL, KEVIN M (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:SMALL
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 1:1033 REGENTS BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6091
Mailing Address - Country:US
Mailing Address - Phone:253-566-6121
Mailing Address - Fax:253-564-8118
Practice Address - Street 1:1033 REGENTS BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6091
Practice Address - Country:US
Practice Address - Phone:253-566-6121
Practice Address - Fax:253-564-8118
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU23084Medicare UPIN
WA001002134Medicare ID - Type Unspecified