Provider Demographics
NPI:1205920105
Name:KIST, JAMES KENNETH (DC)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:KENNETH
Last Name:KIST
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 1:510 WEST 44TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004
Mailing Address - Country:US
Mailing Address - Phone:440-992-1500
Mailing Address - Fax:440-992-8749
Practice Address - Street 1:510 WEST 44TH ST
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004
Practice Address - Country:US
Practice Address - Phone:440-992-1500
Practice Address - Fax:440-992-8749
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2174749Medicaid
OHKI4015481Medicare ID - Type Unspecified
OH2174749Medicaid