Provider Demographics
NPI:1093138190
Name:KENNEDY AVENUE WELLNESS
Entity Type:Organization
Organization Name:KENNEDY AVENUE WELLNESS
Other - Org Name:HIGHLAND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERSLUIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-924-7626
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-0626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2116 45TH ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-3742
Practice Address - Country:US
Practice Address - Phone:219-924-7626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-24
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty