Provider Demographics
NPI:1689604837
Name:BURCK, KENNETH (D C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BURCK
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 W HAPPY VALLEY RD
Mailing Address - Street 2:STE B105
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85310-2608
Mailing Address - Country:US
Mailing Address - Phone:623-572-9820
Mailing Address - Fax:623-572-9830
Practice Address - Street 1:6615 W HAPPY VALLEY RD
Practice Address - Street 2:STE B105
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85310-2608
Practice Address - Country:US
Practice Address - Phone:623-572-9820
Practice Address - Fax:623-572-9830
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4120111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ66533Medicare ID - Type Unspecified
AZU14005Medicare UPIN