Provider Demographics
NPI:1629145164
Name:GRAHAM, KENNETH SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:SCOTT
Last Name:GRAHAM
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 1:2191 S EL CAMINO REAL
Mailing Address - Street 2:STE 105
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-6225
Mailing Address - Country:US
Mailing Address - Phone:760-945-8282
Mailing Address - Fax:
Practice Address - Street 1:2191 S EL CAMINO REAL
Practice Address - Street 2:STE 105
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-6225
Practice Address - Country:US
Practice Address - Phone:760-696-8872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18425111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU01747Medicare UPIN