Provider Demographics
NPI:1144411661
Name:KENNEDY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:KENNEDY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-546-6325
Mailing Address - Street 1:3405 PENROSE PL
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1818
Mailing Address - Country:US
Mailing Address - Phone:303-546-6325
Mailing Address - Fax:303-449-4229
Practice Address - Street 1:3405 PENROSE PL
Practice Address - Street 2:SUITE 106
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1818
Practice Address - Country:US
Practice Address - Phone:303-546-6325
Practice Address - Fax:303-449-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3147261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
T17351Medicare UPIN
DC12443Medicare PIN