Provider Demographics
NPI:1336529882
Name:POULSTON, KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:POULSTON
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 1:1300 PINETREE DR STE 7
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4429
Mailing Address - Country:US
Mailing Address - Phone:321-775-3734
Mailing Address - Fax:
Practice Address - Street 1:1300 PINETREE DR STE 7
Practice Address - Street 2:
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4429
Practice Address - Country:US
Practice Address - Phone:321-775-3734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-30
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11291111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor