Provider Demographics
NPI:1457401895
Name:ANTLEY, SUSAN KINKADE (DC)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KINKADE
Last Name:ANTLEY
Suffix:
Gender:F
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 648
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:MT
Mailing Address - Zip Code:59922-0648
Mailing Address - Country:US
Mailing Address - Phone:406-844-2151
Mailing Address - Fax:
Practice Address - Street 1:7176 HIGHWAY 93 SOUTH
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:MT
Practice Address - Zip Code:59922
Practice Address - Country:US
Practice Address - Phone:406-844-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTCHI 954111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000040033OtherBLUE CROSS BLUE SHIELD
MT0000163999Medicaid