Provider Demographics
NPI:1386632602
Name:GREENBERG, KENNETH MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:GREENBERG
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 1:8312 LAKE MURRAY BLVD
Mailing Address - Street 2:SUITE O
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-3435
Mailing Address - Country:US
Mailing Address - Phone:619-464-8181
Mailing Address - Fax:619-464-8332
Practice Address - Street 1:8312 LAKE MURRAY BLVD
Practice Address - Street 2:SUITE O
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-3435
Practice Address - Country:US
Practice Address - Phone:619-464-8181
Practice Address - Fax:619-464-8332
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19471111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC19471Medicare ID - Type Unspecified