Healthcare Provider Details

I. General information

NPI: 1457401895
Provider Name (Legal Business Name): SUSAN KINKADE ANTLEY D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7176 HIGHWAY 93 SOUTH
LAKESIDE MT
59922
US

IV. Provider business mailing address

PO BOX 648
LAKESIDE MT
59922-0648
US

V. Phone/Fax

Practice location:
  • Phone: 406-844-2151
  • Fax:
Mailing address:
  • Phone: 406-844-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHI 954
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: