Provider Demographics
NPI:1073732509
Name:DAVIS, KENNETH YALE (DC PC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:YALE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DC PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3197
Mailing Address - Country:US
Mailing Address - Phone:201-652-2554
Mailing Address - Fax:201-652-1708
Practice Address - Street 1:60 W RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3197
Practice Address - Country:US
Practice Address - Phone:201-652-2554
Practice Address - Fax:201-652-1708
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ1600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP2059267OtherOXFORD
NJDA450167Medicare ID - Type Unspecified