Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 34360 | CA |
N | 111NR0400X | Rehabilitation Chiropractor | 34360 | CA |
NPI | 1427514009 |
---|---|
Provider Name | Dr. Mackenzie Alexander Kolt |
First Address | Morden, MANITOBA R6M1E7 |
Second Address | West Los Angeles, CA 90025-2589 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/02/2019 |
Last Update Date | 19/02/2019 |