Healthcare Provider Details

I. General information

NPI: 1366948606
Provider Name (Legal Business Name): KEVIN KIPKOECH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GROTTO ST N
ST PAUL MN
55104
US

IV. Provider business mailing address

5381 MADISON ST NE
FRIDLEY MN
55421-1259
US

V. Phone/Fax

Practice location:
  • Phone: 651-760-3236
  • Fax:
Mailing address:
  • Phone: 612-961-8512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2461156
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: