Provider Demographics
NPI:1295865095
Name:WATT, KEVIN S (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:S
Last Name:WATT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:1110 W KETTLEMAN LN
Mailing Address - Street 2:#27
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-6031
Mailing Address - Country:US
Mailing Address - Phone:209-334-2366
Mailing Address - Fax:209-334-2377
Practice Address - Street 1:1110 W KETTLEMAN LN
Practice Address - Street 2:#27
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-6031
Practice Address - Country:US
Practice Address - Phone:209-334-2366
Practice Address - Fax:209-334-2377
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2014-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CADC24027111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU62788Medicare ID - Type Unspecified