Provider Demographics
NPI:1457536872
Name:KIEKHOEFER CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:KIEKHOEFER CHIROPRACTIC LLC
Other - Org Name:KIEKHOEFER CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:KIEKHOEFER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-458-0094
Mailing Address - Street 1:4781 STIMSON TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-8411
Mailing Address - Country:US
Mailing Address - Phone:651-458-0094
Mailing Address - Fax:651-251-2273
Practice Address - Street 1:8619 W POINT DOUGLAS RD S
Practice Address - Street 2:SUITE 110
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4162
Practice Address - Country:US
Practice Address - Phone:651-458-0094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2666261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN673228300Medicaid
MN350001065Medicare PIN