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General NPI Number Information
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NPI Number | 1023828266
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Entity Type | Organization
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Legal Business Name | KMGO ENTERPRISES PLLC
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Dates
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Enumeration Date | 01/09/2025
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Last Update Date | 01/09/2025
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Provider Practice Location Address
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Address Line | 1271 STEAMBOAT DR. SUITE 1
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City | FAYETTEVILLE
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State | AR
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Zip | 72704
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Country | US
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Telephone | 479-435-6834
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Fax | 509-694-8932
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Provider Business Mailing Address
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Address Line | 1271 STEAMBOAT DR. SUITE 1
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City | FAYETTEVILLE
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State | AR
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Zip | 72704
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Country | US
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Telephone | 479-435-6834
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Fax | 509-694-8932
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Authorized Official
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Title or Position | PRESIDENT / OWNER
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Name | DR. KEVIN WATERLOO
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Credential | DC
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Telephone | 479-435-6834
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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