Provider Demographics
NPI:1053395863
Name:KVAM, BRENT ALEXANDER (DC,)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALEXANDER
Last Name:KVAM
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 1:7525 MITCHELL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-1959
Mailing Address - Country:US
Mailing Address - Phone:952-974-2091
Mailing Address - Fax:952-974-2296
Practice Address - Street 1:7525 MITCHELL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-1959
Practice Address - Country:US
Practice Address - Phone:952-974-2091
Practice Address - Fax:952-974-2296
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4188111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU94904Medicare UPIN
MN350002859Medicare ID - Type Unspecified