Provider Demographics
NPI:1104815653
Name:GOSNELL, KENNETH A (CH)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:GOSNELL
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29633-1007
Mailing Address - Country:US
Mailing Address - Phone:864-624-9355
Mailing Address - Fax:864-624-9356
Practice Address - Street 1:120 STRODE CIR
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1484
Practice Address - Country:US
Practice Address - Phone:864-624-9355
Practice Address - Fax:864-624-9356
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH130Medicaid
SCCH2047Medicaid
SCU676610281Medicare UPIN