Provider Demographics
NPI:1922144773
Name:MARSH, KEVIN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ROBERT
Last Name:MARSH
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 1:8235 N CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8683
Mailing Address - Country:US
Mailing Address - Phone:208-762-0222
Mailing Address - Fax:208-762-5362
Practice Address - Street 1:8235 N CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8683
Practice Address - Country:US
Practice Address - Phone:208-762-0222
Practice Address - Fax:208-762-5362
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-699111N00000X
WACH00002763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID350038842OtherRAILROAD MEDICARE
ID002764300Medicaid
26526OtherGROUP HEALTH
WA37099OtherLABOR AND INDUSTRIES
IDC6996OtherBLUE CROSS
ID000010024376OtherREGENCE BLUE SHEILD
ID350038842OtherRAILROAD MEDICARE
ID1673365Medicare ID - Type Unspecified