Provider Demographics
NPI:1922114321
Name:WAHL, SEAN KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:KELLY
Last Name:WAHL
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 1:423 FRONT STREET N
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56514
Mailing Address - Country:US
Mailing Address - Phone:218-354-2148
Mailing Address - Fax:218-354-2168
Practice Address - Street 1:423 FRONT ST NORTH
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56514
Practice Address - Country:US
Practice Address - Phone:218-354-2148
Practice Address - Fax:218-354-2168
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3260111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350001836Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MNU53965Medicare UPIN