Provider Demographics
NPI:1568762441
Name:WINGROVE, KENNETH P (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:WINGROVE
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 1:1700 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6331
Mailing Address - Country:US
Mailing Address - Phone:505-634-9225
Mailing Address - Fax:505-212-1195
Practice Address - Street 1:1700 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6331
Practice Address - Country:US
Practice Address - Phone:505-634-9225
Practice Address - Fax:505-212-1195
Is Sole Proprietor?:No
Enumeration Date:2010-10-26
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11626111N00000X
NM2158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor