Provider Demographics
NPI:1437336641
Name:MACK, KENNETH THOMAS (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:THOMAS
Last Name:MACK
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 1:1525 S ALAFAYA TRL
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8926
Mailing Address - Country:US
Mailing Address - Phone:321-236-8452
Mailing Address - Fax:
Practice Address - Street 1:1525 S ALAFAYA TRL
Practice Address - Street 2:SUITE 102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8926
Practice Address - Country:US
Practice Address - Phone:321-236-8452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1780703397OtherNPI GROUP NUMBER
K7105Medicare UPIN