Provider Demographics
NPI:1598831893
Name:REISENAUER, KENNETH R (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:REISENAUER
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 1:901 SNEATH LN
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-2400
Mailing Address - Country:US
Mailing Address - Phone:650-952-8450
Mailing Address - Fax:
Practice Address - Street 1:901 SNEATH LN
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2400
Practice Address - Country:US
Practice Address - Phone:650-952-8450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110910111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor