Provider Demographics
NPI:1205975364
Name:KRISTENSEN, MICHAEL ALLEN (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:KRISTENSEN
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:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:OGLESBY
Mailing Address - State:IL
Mailing Address - Zip Code:61348-0098
Mailing Address - Country:US
Mailing Address - Phone:815-883-8423
Mailing Address - Fax:815-883-3147
Practice Address - Street 1:646 N COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:OGLESBY
Practice Address - State:IL
Practice Address - Zip Code:61348-1071
Practice Address - Country:US
Practice Address - Phone:815-883-8423
Practice Address - Fax:815-883-3147
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5027036OtherBLUE CROSS BLUE SHIELD
IL5027036OtherBLUE CROSS BLUE SHIELD
IL597430Medicare ID - Type Unspecified