Provider Demographics
NPI:1588722482
Name:PHILLIPS, KEVIN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:PHILLIPS
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 1:112 NW GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2914
Mailing Address - Country:US
Mailing Address - Phone:541-385-1819
Mailing Address - Fax:541-330-6985
Practice Address - Street 1:112 NW GREELEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2914
Practice Address - Country:US
Practice Address - Phone:541-385-1819
Practice Address - Fax:541-330-6985
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU96656Medicare UPIN
OR116731Medicare ID - Type UnspecifiedCHIROPRACTOR