Provider Demographics
NPI:1447291331
Name:SECREST, KAY K (DC)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:K
Last Name:SECREST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 STEELE ST
Mailing Address - Street 2:
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-1265
Mailing Address - Country:US
Mailing Address - Phone:920-487-9909
Mailing Address - Fax:877-898-0965
Practice Address - Street 1:316 STEELE ST
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-1265
Practice Address - Country:US
Practice Address - Phone:920-487-9909
Practice Address - Fax:877-898-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1307111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1307OtherSTATE LICENSE NUMBER
WIT63294Medicare UPIN