Provider Demographics
NPI:1417094368
Name:HEINEN, KENNETH S (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
Last Name:HEINEN
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 1:1539 33RD PLACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1826
Mailing Address - Country:US
Mailing Address - Phone:920-451-9960
Mailing Address - Fax:920-451-9965
Practice Address - Street 1:1539 33RD PLACE
Practice Address - Street 2:SUITE B
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1826
Practice Address - Country:US
Practice Address - Phone:920-451-9960
Practice Address - Fax:920-451-9965
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3643-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38927500Medicaid
WI35269Medicare ID - Type Unspecified
WIU81839Medicare UPIN
WI38927500Medicaid