Provider Demographics
NPI:1720486699
Name:WATERLOO, KEVIN (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:WATERLOO
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 1:2317 E MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4415
Mailing Address - Country:US
Mailing Address - Phone:870-520-6351
Mailing Address - Fax:870-520-6353
Practice Address - Street 1:2317 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4415
Practice Address - Country:US
Practice Address - Phone:870-520-6351
Practice Address - Fax:870-520-6353
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC010974111N00000X
AR16266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor