Provider Demographics
NPI:1790960813
Name:STILLWELL, KENNETH RAY (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:STILLWELL
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 1:4537 YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-4929
Mailing Address - Country:US
Mailing Address - Phone:253-475-3334
Mailing Address - Fax:253-475-0875
Practice Address - Street 1:4537 YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-4929
Practice Address - Country:US
Practice Address - Phone:253-475-3334
Practice Address - Fax:253-475-0875
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001328111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8857016Medicare PIN