Healthcare Provider Details

I. General information

NPI: 1568794378
Provider Name (Legal Business Name): KRISTINE KOPP D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 STATE RD UNIT 12
VINEYARD HAVEN MA
02568-5695
US

IV. Provider business mailing address

455 STATE RD UNIT 12
VINEYARD HAVEN MA
02568-5695
US

V. Phone/Fax

Practice location:
  • Phone: 508-696-1863
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR008606
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: