Provider Demographics
NPI:1255587952
Name:KENT HAGAN CHIROPRACTIC, INC
Entity type:Organization
Organization Name:KENT HAGAN CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:510-581-5813
Mailing Address - Street 1:95 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-1905
Mailing Address - Country:US
Mailing Address - Phone:510-581-5813
Mailing Address - Fax:510-581-7216
Practice Address - Street 1:95 JACKSON ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-1905
Practice Address - Country:US
Practice Address - Phone:510-581-5813
Practice Address - Fax:510-581-7216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0198130Medicare UPIN