Provider Demographics
NPI:1649783994
Name:VIESER, KEVIN ELLIS (DC, ATC, CCSP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:ELLIS
Last Name:VIESER
Suffix:
Gender:M
Credentials:DC, ATC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 OAK MANOR DR STE 101
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-5553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 OAK MANOR DR STE 101
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-5553
Practice Address - Country:US
Practice Address - Phone:410-766-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2020-11-24
Deactivation Date:2020-11-19
Deactivation Code:
Reactivation Date:2020-11-24
Provider Licenses
StateLicense IDTaxonomies
MDC16755111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician