Provider Demographics
NPI:1639358088
Name:KENNEDY, MICHAEL JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:KENNEDY
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 1:6409 CITY WEST PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7845
Mailing Address - Country:US
Mailing Address - Phone:952-833-3038
Mailing Address - Fax:952-833-3040
Practice Address - Street 1:12105 41ST AVE N
Practice Address - Street 2:APT 118
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-1200
Practice Address - Country:US
Practice Address - Phone:952-607-6416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4999111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor