Provider Demographics
NPI:1538635214
Name:KENNEDY AVENUE CHIROPRACTIC
Entity Type:Organization
Organization Name:KENNEDY AVENUE CHIROPRACTIC
Other - Org Name:KENNEDY AVE WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:R
Authorized Official - Last Name:SPROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-629-2312
Mailing Address - Street 1:8145 KENNEDY AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1128
Mailing Address - Country:US
Mailing Address - Phone:219-803-6630
Mailing Address - Fax:219-937-7237
Practice Address - Street 1:8145 KENNEDY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1128
Practice Address - Country:US
Practice Address - Phone:219-803-6630
Practice Address - Fax:219-937-7237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-19
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013370Medicaid