Provider Demographics
NPI:1851775381
Name:KEVIN S & TINA S WATT
Entity Type:Organization
Organization Name:KEVIN S & TINA S WATT
Other - Org Name:WOODLAKE CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WATT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:209-334-2366
Mailing Address - Street 1:1110 W KETTLEMAN LN
Mailing Address - Street 2:27
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6031
Mailing Address - Country:US
Mailing Address - Phone:209-334-2366
Mailing Address - Fax:209-334-2377
Practice Address - Street 1:1110 W KETTLEMAN LN
Practice Address - Street 2:27
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6031
Practice Address - Country:US
Practice Address - Phone:209-334-2366
Practice Address - Fax:209-334-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-14
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty