Provider Demographics
NPI:1639108079
Name:WEIL, KENNETH ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:WEIL
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 1:1715 HOWELL MILL RD NW STE C12
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-3117
Mailing Address - Country:US
Mailing Address - Phone:404-350-8000
Mailing Address - Fax:404-350-8072
Practice Address - Street 1:1715 HOWELL MILL RD NW
Practice Address - Street 2:C-12
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-3121
Practice Address - Country:US
Practice Address - Phone:404-350-8000
Practice Address - Fax:404-350-8072
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5608111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDQPOtherMEDICARE
GA672394OtherBLUE CROSS BLUE SHIELD #