Provider Demographics
NPI:1003883034
Name:KADDATZ, CRAIG ROY (DC)
Entity type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:ROY
Last Name:KADDATZ
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 1:130 1ST STREET W #108
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:MN
Mailing Address - Zip Code:56220-1145
Mailing Address - Country:US
Mailing Address - Phone:507-223-7366
Mailing Address - Fax:507-223-7366
Practice Address - Street 1:130 1ST STREET W #108
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:MN
Practice Address - Zip Code:56220-1145
Practice Address - Country:US
Practice Address - Phone:507-233-7366
Practice Address - Fax:507-223-7366
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2538111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0851OtherHSM ID
22124OtherSVHP ID
MN7603720Medicaid
MN1DO74KAOtherBCBS INDIVIDUAL ID
15097OtherMIDLANDS CHOICE ID
MN59873KAOtherBCBS GROUP ID
MN602028300Medicaid
2038OtherDAKOTACARE ID
T65689Medicare UPIN
2038OtherDAKOTACARE ID