Kellen Blanck-Grott, D.C.
Individual provider Active NPI Chiropractor · Crivitz, WI
NPI 1306200472 · NPPES record last updated Jul 12, 2018
Key facts
- NPI
- 1306200472
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Chiropractor 111N00000X
- License
- 5160-12 (WI)
- Practice address
- 709 Dyer St
Crivitz, WI 54114 - Phone
- (715) 854-5025
- NPI assigned
- Apr 5, 2016
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161017002543 | WI | Practitioner - Chiropractic | 4082902598 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 5160-12 | WI | MD | Chiropractor |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Northern Chiropractic and Wellness LLC | Chiropractor | Current |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Chiropractor | 111N00000X | 5160-12 | WI | Yes |
Addresses
Primary practice location
709 Dyer St
Crivitz, WI 54114
Mailing address
709 Dyer St
Crivitz, WI 54114-7480
Phone (715) 854-5025
Other practice location 1
119 Congress St
Oconto, WI 54153-1533
Phone (715) 854-5025
Other providers in Crivitz, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 12, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.