Provider Demographics
NPI:1861414062
Name:KIESELBACH, STEPHEN P (DC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:P
Last Name:KIESELBACH
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 1:3408-1 VIRGINIA AVE.
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078
Mailing Address - Country:US
Mailing Address - Phone:276-647-1903
Mailing Address - Fax:276-647-1903
Practice Address - Street 1:3408-1 VIRGINIA AVE.
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24078
Practice Address - Country:US
Practice Address - Phone:276-647-1903
Practice Address - Fax:276-647-1903
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8700111N00000X
WV975111N00000X
VA0104556547111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA190001969Medicare PIN
FLU94927Medicare UPIN