MEDICARE: DR. MACKENZIE ALEXANDER KOLT DC

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	34360	CA
2	111NR0400X	Rehabilitation Chiropractor	34360	CA

General Provider Information

NPI Number	:	1427514009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MACKENZIE ALEXANDER KOLT DC

Provider Business Mailing Address
First Line	:	515 STEPHEN ST
Second Line	:
City	:	MORDEN
State	:	MANITOBA
Zip	:	R6M1E7
Country	:	CA
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12217 SANTA MONICA BLVD STE 208
Second Line	:
City	:	WEST LOS ANGELES
State	:	CA
Zip	:	90025-2589
Country	:	US
Telephone Number	:	310-447-3540
Fax Number	:

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

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	02/19/2019

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