Provider Demographics
NPI:1194595660
Name:KENNING, SHANE (DC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:KENNING
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 1:1711 BRANHAM LN STE A12
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-5212
Mailing Address - Country:US
Mailing Address - Phone:408-269-7111
Mailing Address - Fax:408-269-7110
Practice Address - Street 1:1711 BRANHAM LN STE A12
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-5212
Practice Address - Country:US
Practice Address - Phone:408-269-7111
Practice Address - Fax:408-269-7110
Is Sole Proprietor?:No
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA34586111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor