Provider Demographics
NPI:1508935362
Name:KENNEDY, MIA M (DC)
Entity Type:Individual
Prefix:MRS
First Name:MIA
Middle Name:M
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3120
Mailing Address - Country:US
Mailing Address - Phone:540-375-9220
Mailing Address - Fax:540-375-9229
Practice Address - Street 1:1461 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3120
Practice Address - Country:US
Practice Address - Phone:540-375-9220
Practice Address - Fax:540-375-9229
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA350669OtherANTHEM PROVIDER NUMBER
VAMC10583Medicare PIN