1366448276 NPI number — DR. KYLE JOHN PANKONIN DC

Table of content: DR. KYLE JOHN PANKONIN DC (NPI 1366448276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366448276 NPI number — DR. KYLE JOHN PANKONIN DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANKONIN
Provider First Name:
KYLE
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366448276
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 517
Provider Business Mailing Address City Name:
LAMBERTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56152-1377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-752-7650
Provider Business Mailing Address Fax Number:
507-752-7635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
214 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAMBERTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56152-1377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-752-7650
Provider Business Practice Location Address Fax Number:
507-752-7635
Provider Enumeration Date:
06/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC3858 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15F52RE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 411508205 . This is a "HEALTH SERVICES MANAGEMEN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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