Provider Demographics
NPI:1811090483
Name:KETTELER, REID S (DC)
Entity type:Individual
Prefix:DR
First Name:REID
Middle Name:S
Last Name:KETTELER
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 1:5363 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66226-3938
Mailing Address - Country:US
Mailing Address - Phone:913-422-8929
Mailing Address - Fax:913-422-0061
Practice Address - Street 1:5363 ROBERTS ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66226-3938
Practice Address - Country:US
Practice Address - Phone:913-422-8929
Practice Address - Fax:913-422-0061
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4670111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
629155OtherUHC
MO27843012OtherBCBS
KS452211OtherBCBS
7811171OtherAETNA
629155OtherUHC
000A834Medicare ID - Type Unspecified