Provider Demographics
NPI:1306200472
Name:BLANCK-GROTT, KELLEN (DC)
Entity type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:BLANCK-GROTT
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 1:709 DYER ST
Mailing Address - Street 2:
Mailing Address - City:CRIVITZ
Mailing Address - State:WI
Mailing Address - Zip Code:54114-7480
Mailing Address - Country:US
Mailing Address - Phone:715-854-5025
Mailing Address - Fax:
Practice Address - Street 1:709 DYER ST
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114
Practice Address - Country:US
Practice Address - Phone:715-854-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5160-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor