Provider Demographics
NPI:1225066632
Name:CRANDELL, KENNETH LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:CRANDELL
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 1:11657 NE GLISAN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220
Mailing Address - Country:US
Mailing Address - Phone:503-252-5118
Mailing Address - Fax:503-252-3199
Practice Address - Street 1:11657 NE GLISAN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-252-5118
Practice Address - Fax:503-252-3199
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1923111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR072702Medicaid
OR072702Medicaid