Provider Demographics
NPI:1669505780
Name:BASILLE, KENNETH JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:BASILLE
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:PO BOX 941188
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31141-0188
Mailing Address - Country:US
Mailing Address - Phone:678-701-2225
Mailing Address - Fax:678-701-2226
Practice Address - Street 1:2810 SPRING RD SE
Practice Address - Street 2:SUITE 116
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3000
Practice Address - Country:US
Practice Address - Phone:678-217-7700
Practice Address - Fax:678-217-7701
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006985111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor