Provider Demographics
NPI:1265560577
Name:CHRISTIANSON, KENT (DC)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:
Last Name:CHRISTIANSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 N RIVER RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8949
Mailing Address - Country:US
Mailing Address - Phone:630-548-0700
Mailing Address - Fax:630-548-9070
Practice Address - Street 1:640 N RIVER RD
Practice Address - Street 2:SUITE 114
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8949
Practice Address - Country:US
Practice Address - Phone:630-548-0700
Practice Address - Fax:630-548-9070
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-008040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU65887Medicare UPIN
ILK45616Medicare PIN