Provider Demographics
NPI:1972694594
Name:WHEAT, KEVIN JAMES (DC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:WHEAT
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 1:1001 DIAMOND RDG STE 900
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-6839
Mailing Address - Country:US
Mailing Address - Phone:573-636-3555
Mailing Address - Fax:573-634-3545
Practice Address - Street 1:1001 DIAMOND RDG STE 900
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6839
Practice Address - Country:US
Practice Address - Phone:573-636-3555
Practice Address - Fax:573-634-3545
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005037600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U91231Medicare UPIN
MO000014817Medicare PIN