Provider Demographics
NPI:1609934934
Name:SHEPPARD, KENNY R (DC)
Entity Type:Individual
Prefix:
First Name:KENNY
Middle Name:R
Last Name:SHEPPARD
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 1:634 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-2422
Mailing Address - Country:US
Mailing Address - Phone:858-350-6290
Mailing Address - Fax:858-350-6775
Practice Address - Street 1:634 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-2422
Practice Address - Country:US
Practice Address - Phone:858-350-6290
Practice Address - Fax:858-350-6775
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC16059Medicare ID - Type Unspecified
CAT18235Medicare UPIN