Provider Demographics
NPI:1861422677
Name:KRUSE, KEVAN D (DC)
Entity type:Individual
Prefix:DR
First Name:KEVAN
Middle Name:D
Last Name:KRUSE
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 1:641 W LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5911
Mailing Address - Country:US
Mailing Address - Phone:813-654-5413
Mailing Address - Fax:813-643-1457
Practice Address - Street 1:641 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5911
Practice Address - Country:US
Practice Address - Phone:813-654-5413
Practice Address - Fax:813-643-1457
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 6698111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3815919-00Medicaid
FLU57312Medicare UPIN
FL55335YMedicare ID - Type Unspecified
FLK8865Medicare PIN