Provider Demographics
NPI:1588753651
Name:YOUNG, KEVIN WALLACE (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WALLACE
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 MEDICAL CENTER PT
Mailing Address - Street 2:SUITE #115
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907
Mailing Address - Country:US
Mailing Address - Phone:719-578-1420
Mailing Address - Fax:719-578-1591
Practice Address - Street 1:1625 MEDICAL CENTER PT
Practice Address - Street 2:SUITE #115
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907
Practice Address - Country:US
Practice Address - Phone:719-578-1420
Practice Address - Fax:719-578-1591
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2443111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC27053Medicare ID - Type Unspecified