Provider Demographics
NPI:1427514009
Name:KOLT, MACKENZIE ALEXANDER (DC)
Entity type:Individual
Prefix:DR
First Name:MACKENZIE
Middle Name:ALEXANDER
Last Name:KOLT
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 1:515 STEPHEN ST
Mailing Address - Street 2:
Mailing Address - City:MORDEN
Mailing Address - State:MANITOBA
Mailing Address - Zip Code:R6M1E7
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12217 SANTA MONICA BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WEST LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2589
Practice Address - Country:US
Practice Address - Phone:310-447-3540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34360111N00000X, 111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation