Provider Demographics
NPI:1144369844
Name:VAN WYK, KENNETH WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:VAN WYK
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 1:911 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1503
Mailing Address - Country:US
Mailing Address - Phone:641-628-3511
Mailing Address - Fax:
Practice Address - Street 1:911 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1503
Practice Address - Country:US
Practice Address - Phone:641-628-3511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01447OtherBLUE SHIELD
IA47928OtherBLUE SHIELD
IA1014472Medicaid
IA0014472Medicaid
IA1014472Medicaid
IA47928OtherBLUE SHIELD
IA01447Medicare ID - Type Unspecified