Provider Demographics
NPI:1285894329
Name:KEVIN T SIMONS DC LLC
Entity type:Organization
Organization Name:KEVIN T SIMONS DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-686-7330
Mailing Address - Street 1:2510 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4858
Mailing Address - Country:US
Mailing Address - Phone:920-686-7330
Mailing Address - Fax:920-686-7510
Practice Address - Street 1:2510 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-4858
Practice Address - Country:US
Practice Address - Phone:920-686-7330
Practice Address - Fax:920-686-7510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38888600Medicaid
WIP00146537OtherRAILROAD MEDICARE
WIU51053Medicare UPIN
WI000035585Medicare PIN