Provider Demographics
NPI:1659914992
Name:MITTELSTADT, KENNETH GRANT (DACM, DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GRANT
Last Name:MITTELSTADT
Suffix:
Gender:M
Credentials:DACM, DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8088 OLD AUSTIN RD UNIT 2A
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:TX
Mailing Address - Zip Code:78154-3377
Mailing Address - Country:US
Mailing Address - Phone:830-743-9663
Mailing Address - Fax:
Practice Address - Street 1:8088 OLD AUSTIN RD UNIT 2A
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:TX
Practice Address - Zip Code:78154-3377
Practice Address - Country:US
Practice Address - Phone:830-743-9663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18282171100000X
TXAC02078171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty