MEDICARE: KEVIN M STATOM D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5165	KY

General Provider Information

NPI Number	:	1033265269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN M STATOM D.C.

Provider Business Mailing Address
First Line	:	2210 MEADOW DR
Second Line	:	STE 5
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1374
Country	:	US
Telephone Number	:	502-822-1668
Fax Number	:

Provider Business Practice Location Address
First Line	:	2210 MEADOW DR
Second Line	:	STE 5
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1374
Country	:	US
Telephone Number	:	502-822-1668
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	04/03/2015

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