Provider Demographics
NPI:1124107529
Name:DUDLEY, KENNETH MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:DUDLEY
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 1:1021 W BUCHANAN ST STE 17
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-1238
Mailing Address - Country:US
Mailing Address - Phone:573-796-8150
Mailing Address - Fax:573-796-8140
Practice Address - Street 1:1021 W BUCHANAN ST STE 17
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1238
Practice Address - Country:US
Practice Address - Phone:573-796-8150
Practice Address - Fax:573-796-8140
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO31977OtherBLUECROSS BLUESHIELD
MO610798OtherAMERICAN CHIROPRACTIC NET
MO245812OtherHEALTHLINK