Provider Demographics
NPI:1346336096
Name:URBAN, KENNETH A (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:URBAN
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 1:1624 E MASON ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54302-2739
Mailing Address - Country:US
Mailing Address - Phone:920-465-0400
Mailing Address - Fax:920-465-1430
Practice Address - Street 1:1624 E MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54302-2739
Practice Address - Country:US
Practice Address - Phone:920-465-0400
Practice Address - Fax:920-465-1430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1483111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38757000Medicaid
WI38757000Medicaid