Provider Demographics
NPI:1710068838
Name:KETCHMARK, CHRIS A
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:A
Last Name:KETCHMARK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072
Mailing Address - Country:US
Mailing Address - Phone:320-245-2499
Mailing Address - Fax:320-245-2539
Practice Address - Street 1:301 N COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072
Practice Address - Country:US
Practice Address - Phone:320-245-2499
Practice Address - Fax:320-245-2539
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3570111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0370OtherHSM
MN00B12NOOtherBCBSM
MN4400039OtherMEDICA