Provider Demographics
NPI:1053403006
Name:LASTINE, KRIS BLAINE (DC)
Entity type:Individual
Prefix:DR
First Name:KRIS
Middle Name:BLAINE
Last Name:LASTINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1411 E COLLEGE DR
Mailing Address - Street 2:STE 4
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258
Mailing Address - Country:US
Mailing Address - Phone:507-537-1475
Mailing Address - Fax:507-537-9498
Practice Address - Street 1:1411 E COLLEGE DR
Practice Address - Street 2:STE 4
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258
Practice Address - Country:US
Practice Address - Phone:507-537-1475
Practice Address - Fax:507-537-9498
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2194111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350005213OtherNEW MEDICARE PROVIDER PTAN # 03/01/2013
MN59611LAOtherBCBS OF MN
MN891228900Medicaid
P00056482OtherRAILROAD MEDICARE
MN891228900Medicaid