Provider Demographics
NPI:1174748974
Name:KENWOD CHIROPRACTIC OFFICE
Entity type:Organization
Organization Name:KENWOD CHIROPRACTIC OFFICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAKRAJSEK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-724-6008
Mailing Address - Street 1:1410 KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2344
Mailing Address - Country:US
Mailing Address - Phone:218-724-6008
Mailing Address - Fax:218-724-4499
Practice Address - Street 1:1410 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2344
Practice Address - Country:US
Practice Address - Phone:218-724-6008
Practice Address - Fax:218-724-4499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2876111N00000X
WI2398-012111N00000X
MN2601111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350035360OtherRR MEDICARE-TIM ZAKRAJSEK
MN751828500Medicaid
MNC06877Medicare PIN
MNT66316Medicare UPIN
MN359000330Medicare ID - Type UnspecifiedMEDICARE - TIM ZAKRAJSEK
MN350035360OtherRR MEDICARE-TIM ZAKRAJSEK
MNV17944Medicare UPIN