Healthcare Provider Details

I. General information

NPI: 1861422677
Provider Name (Legal Business Name): KEVAN D. KRUSE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 W LUMSDEN RD
BRANDON FL
33511-5911
US

IV. Provider business mailing address

641 W LUMSDEN RD
BRANDON FL
33511-5911
US

V. Phone/Fax

Practice location:
  • Phone: 813-654-5413
  • Fax: 813-643-1457
Mailing address:
  • Phone: 813-654-5413
  • Fax: 813-643-1457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCH 6698
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: