Provider Demographics
NPI:1356425367
Name:THIELE, KENNETH LEO (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEO
Last Name:THIELE
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 1:430 SOUTH BROAD ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-387-5591
Mailing Address - Fax:507-387-5397
Practice Address - Street 1:430 SOUTH BROAD ST
Practice Address - Street 2:SUITE 130
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-387-5591
Practice Address - Fax:507-387-5397
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN788725600Medicaid
MN788725600Medicaid
359000266Medicare ID - Type Unspecified