Provider Demographics
NPI:1467559872
Name:KENNEDY, DOUGLAS ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ROBERT
Last Name:KENNEDY
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 1:4578 TALLY HO TRL
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3862
Mailing Address - Country:US
Mailing Address - Phone:303-817-0965
Mailing Address - Fax:303-845-6359
Practice Address - Street 1:4578 TALLY HO TRL
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3862
Practice Address - Country:US
Practice Address - Phone:303-817-0965
Practice Address - Fax:303-845-6359
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor