Provider Demographics
NPI:1043382559
Name:LICCIARDI, KENNETH T (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:T
Last Name:LICCIARDI
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 1:810 NW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601-4253
Mailing Address - Country:US
Mailing Address - Phone:352-378-7888
Mailing Address - Fax:352-378-4130
Practice Address - Street 1:810 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-4253
Practice Address - Country:US
Practice Address - Phone:352-378-7888
Practice Address - Fax:352-378-4130
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55794Medicare UPIN