Provider Demographics
NPI:1366525073
Name:ROSS, KENNETH STEVEN (DC JD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:STEVEN
Last Name:ROSS
Suffix:
Gender:M
Credentials:DC JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SAUSALITO BLVD
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5764
Mailing Address - Country:US
Mailing Address - Phone:407-936-7999
Mailing Address - Fax:407-386-6254
Practice Address - Street 1:172 SAUSALITO BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5764
Practice Address - Country:US
Practice Address - Phone:407-936-7999
Practice Address - Fax:407-386-6254
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0004634111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050508100Medicaid
CH4634OtherLIC NUMBER
70443AMedicare ID - Type Unspecified
FL050508100Medicaid