Provider Demographics
NPI:1528142007
Name:TWEEDT, KENDRICK L (DC, CCSP)
Entity type:Individual
Prefix:
First Name:KENDRICK
Middle Name:L
Last Name:TWEEDT
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8752 W OVERLAND RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1604
Mailing Address - Country:US
Mailing Address - Phone:208-323-2833
Mailing Address - Fax:208-323-2834
Practice Address - Street 1:8752 W OVERLAND RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1604
Practice Address - Country:US
Practice Address - Phone:208-323-2833
Practice Address - Fax:208-323-2834
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACHIA732111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU55365Medicare UPIN
ID1673551Medicare ID - Type Unspecified