Provider Demographics
NPI:1679593461
Name:KICKHAVER, JOSHUA J (DC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:J
Last Name:KICKHAVER
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 1:601 S 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-3958
Mailing Address - Country:US
Mailing Address - Phone:715-848-2526
Mailing Address - Fax:
Practice Address - Street 1:4250 10TH ST
Practice Address - Street 2:
Practice Address - City:MENOMINEE
Practice Address - State:MI
Practice Address - Zip Code:49858-1312
Practice Address - Country:US
Practice Address - Phone:906-863-8410
Practice Address - Fax:906-863-1242
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4231-012111N00000X
MI2301009285111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI144951704OtherUPHP
WI38969300Medicaid
MI144951704Medicaid
MI144951704Medicaid
MI144951704OtherUPHP
V09766Medicare UPIN