Provider Demographics
NPI:1669715686
Name:STORM, KEVIN (DC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:STORM
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 1:116 W SOUTHPORT RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-4063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:622 N MADISON AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4052
Practice Address - Country:US
Practice Address - Phone:317-509-7288
Practice Address - Fax:317-508-4463
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002734A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor