=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093358186
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KONDRAD CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2019
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 CLARK RD
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-923-4357
-----------------------------------------------------
Fax | 941-923-9943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3220 CLARK RD
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34231-8302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-923-4357
-----------------------------------------------------
Fax | 941-923-9943
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTOPHER SCOTT KONDRAD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 302-562-3314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------