Provider Demographics
NPI:1033344874
Name:KALLENBACH, MOLLY MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:MARIE
Last Name:KALLENBACH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 CENTENNIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3304
Mailing Address - Country:US
Mailing Address - Phone:719-475-8676
Mailing Address - Fax:888-457-7282
Practice Address - Street 1:4675 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-3304
Practice Address - Country:US
Practice Address - Phone:719-475-8676
Practice Address - Fax:888-457-7282
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCHR5766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4655Medicare PIN