Provider Demographics
NPI:1083845184
Name:KENNEDY CHIROPRACTIC HEALTH AND WELLNESS CENTER INC
Entity type:Organization
Organization Name:KENNEDY CHIROPRACTIC HEALTH AND WELLNESS CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:949-305-1790
Mailing Address - Street 1:15550 ROCKFIELD BLVD
Mailing Address - Street 2:B220
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2720
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:11 MAREBLU
Practice Address - Street 2:120
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3066
Practice Address - Country:US
Practice Address - Phone:949-305-1790
Practice Address - Fax:949-305-1801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-06
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28686111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28686OtherCHIROPRACTIC LICENSE