Provider Demographics
NPI:1760483986
Name:ANDERSEN, KENNETH RAYMOND (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAYMOND
Last Name:ANDERSEN
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 1:9035 S 1300 E
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3131
Mailing Address - Country:US
Mailing Address - Phone:801-572-5696
Mailing Address - Fax:801-572-5753
Practice Address - Street 1:9035 S 1300 E
Practice Address - Street 2:SUITE 2B
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3132
Practice Address - Country:US
Practice Address - Phone:801-572-5696
Practice Address - Fax:801-572-5753
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49216121202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005761201Medicare ID - Type Unspecified