Provider Demographics
NPI:1104059203
Name:KEVIN S & TINA S WATT
Entity type:Organization
Organization Name:KEVIN S & TINA S WATT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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 1:1822 W KETTLEMAN LN
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4218
Mailing Address - Country:US
Mailing Address - Phone:209-334-2366
Mailing Address - Fax:209-334-2377
Practice Address - Street 1:1822 W KETTLEMAN LN
Practice Address - Street 2:SUITE 5
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4218
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:2009-08-24
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0240270111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U62788Medicare UPIN
CADC0240270Medicare PIN