MEDICARE: KC SPINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	01-05902	KS

General Provider Information

NPI Number	:	1184100034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KC SPINE, LLC

Provider Business Mailing Address
First Line	:	12482 SLATER LN
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66213-1773
Country	:	US
Telephone Number	:	913-475-5193
Fax Number	:

Provider Business Practice Location Address
First Line	:	1707 E CEDAR ST STE 108
Second Line	:
City	:	OLATHE
State	:	KS
Zip	:	66062-1886
Country	:	US
Telephone Number	:	913-318-3003
Fax Number	:

Authorized Official
Title or Position	:	OWNER / CHIROPRACTOR
Name	:	DR. CAMEON M BLAKE
Credential	:	DC
Telephone Number	:	913-475-5193

Provider Enumeration Date	:	07/13/2018
Last Update Date	:	03/19/2019

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Directions to “KC SPINE, LLC ” Practice Location

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