Provider Demographics
NPI: | 1114927555 |
---|---|
Name: | KOZLOWSKI, KENNETH MICHAEL (DC) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KENNETH |
Middle Name: | MICHAEL |
Last Name: | KOZLOWSKI |
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: | 2909 4TH ST N |
Mailing Address - Street 2: | |
Mailing Address - City: | ST PETERSBURG |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33704-2103 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-823-7308 |
Mailing Address - Fax: | 727-824-8855 |
Practice Address - Street 1: | 2909 4TH ST N |
Practice Address - Street 2: | |
Practice Address - City: | ST PETERSBURG |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33704-2103 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-823-7308 |
Practice Address - Fax: | 727-824-8855 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-07-28 |
Last Update Date: | 2021-12-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | CH-5134 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 380607300 | Medicaid | |
FL | 4405292 | Other | UHC |
FL | 517289 | Other | FIRST HEALTH NETWORD |
FL | 5056815 | Other | CCM |
FL | 70742 | Other | BCBS |
FL | 4480189 | Other | AETNA |
FL | 5056815 | Other | CCM |
FL | 380607300 | Medicaid |