Provider Demographics
NPI:1235251638
Name:LARGE, KENNETH B (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:LARGE
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 1:28629 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-4105
Mailing Address - Country:US
Mailing Address - Phone:586-558-4227
Mailing Address - Fax:
Practice Address - Street 1:28629 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4105
Practice Address - Country:US
Practice Address - Phone:586-558-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235251638Medicare PIN
MIOH25256Medicare PIN