Basic Information
| Provider Information | |||||||||
| NPI: | 1619057007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELM | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 HIGHWAY 100 S | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1660 HIGHWAY 100 S | ||||||||
| Address2: | SUITE 145 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554161529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524566160 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 10/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 4573 | MN | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 378L8KE | 01 | MN | BCBS INDIVIDUAL PROVIDER | OTHER | 378L7PI | 01 | MN | BCBS PROVIDER GROUPNUMBER | OTHER |