Provider Demographics
NPI:1710197710
Name:BERG, KEVIN ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ANTHONY
Last Name:BERG
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 1:6120 WASHBURN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2851
Mailing Address - Country:US
Mailing Address - Phone:612-386-8636
Mailing Address - Fax:
Practice Address - Street 1:8200 HUMBOLDT AVE S STE 204
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55431-1432
Practice Address - Country:US
Practice Address - Phone:952-884-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3642111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor