Provider Demographics
NPI:1457333122
Name:MYERS, KENNETH PATRICK (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:PATRICK
Last Name:MYERS
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 1:9033 BASELINE RD
Mailing Address - Street 2:SUITE Q
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-1255
Mailing Address - Country:US
Mailing Address - Phone:909-945-8721
Mailing Address - Fax:909-980-9301
Practice Address - Street 1:9033 BASELINE RD
Practice Address - Street 2:SUITE Q
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1255
Practice Address - Country:US
Practice Address - Phone:909-945-8721
Practice Address - Fax:909-980-9301
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29455111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV05755Medicare UPIN
CADC0294550Medicare ID - Type Unspecified