Provider Demographics
NPI:1417618596
Name:KENNINGTON, MARK A (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:KENNINGTON
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 1:214 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-3535
Mailing Address - Country:US
Mailing Address - Phone:208-217-5122
Mailing Address - Fax:
Practice Address - Street 1:104 S DAISY ST # A
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-4333
Practice Address - Country:US
Practice Address - Phone:208-756-2202
Practice Address - Fax:208-756-2213
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT80175481202111N00000X
IDCHIA-2344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor