Provider Demographics
NPI:1124763230
Name:GUBBELS, SCOT
Entity type:Individual
Prefix:
First Name:SCOT
Middle Name:
Last Name:GUBBELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17316 KENYON AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6910
Mailing Address - Country:US
Mailing Address - Phone:952-236-0767
Mailing Address - Fax:
Practice Address - Street 1:17316 KENYON AVE STE 103
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6910
Practice Address - Country:US
Practice Address - Phone:952-236-0767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6982111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor