Provider Demographics
NPI:1205012747
Name:KENNEDY, MICHAEL DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:KENNEDY
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 1:916 W DALLAS ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-2234
Mailing Address - Country:US
Mailing Address - Phone:936-539-5339
Mailing Address - Fax:936-539-5376
Practice Address - Street 1:916 W DALLAS ST
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-2234
Practice Address - Country:US
Practice Address - Phone:936-539-5339
Practice Address - Fax:936-539-5376
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601933Medicare UPIN