Provider Demographics
NPI:1235450917
Name:RIES, KENLY LEONARD (DC)
Entity Type:Individual
Prefix:DR
First Name:KENLY
Middle Name:LEONARD
Last Name:RIES
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 1:100 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6878
Mailing Address - Country:US
Mailing Address - Phone:928-367-4640
Mailing Address - Fax:928-367-5572
Practice Address - Street 1:100 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6878
Practice Address - Country:US
Practice Address - Phone:928-367-4640
Practice Address - Fax:928-367-5572
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8127111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor