MEDICARE: KOLT CHIROPRACTIC WELLNESS CENTER INC

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

General Provider Information

NPI Number	:	1376000927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOLT CHIROPRACTIC WELLNESS CENTER INC

Provider Business Mailing Address
First Line	:	12217 SANTA MONICA BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2589
Country	:	US
Telephone Number	:	310-447-3540
Fax Number	:

Provider Business Practice Location Address
First Line	:	12217 SANTA MONICA BLVD STE 208
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2589
Country	:	US
Telephone Number	:	310-447-3540
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. MACKENZIE KOLT
Credential	:	DC
Telephone Number	:	204-362-7043

Provider Enumeration Date	:	03/01/2019
Last Update Date	:	03/01/2019

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