Provider Demographics
NPI:1083723597
Name:DONOVAN, KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:DONOVAN
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 1:3715 PATRIOT WAY STE 143
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6901
Mailing Address - Country:US
Mailing Address - Phone:910-395-2774
Mailing Address - Fax:910-395-2474
Practice Address - Street 1:3715 PATRIOT WAY STE 143
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6901
Practice Address - Country:US
Practice Address - Phone:910-395-2774
Practice Address - Fax:910-395-2474
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2688111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085T2OtherBC/BS
NC2455365Medicare ID - Type Unspecified
NCU91559Medicare UPIN