Provider Demographics
NPI:1821492695
Name:KENNEDY PAIN CLINIC GROUP LLC
Entity Type:Organization
Organization Name:KENNEDY PAIN CLINIC GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER , PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:NANCIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BRENES
Authorized Official - Suffix:
Authorized Official - Credentials:AP, DOM
Authorized Official - Phone:941-751-2345
Mailing Address - Street 1:5255 OFFICE PARK BLVD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203
Mailing Address - Country:US
Mailing Address - Phone:941-751-2345
Mailing Address - Fax:
Practice Address - Street 1:5255 OFFICE PARK BLVD
Practice Address - Street 2:SUITE 107
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203
Practice Address - Country:US
Practice Address - Phone:941-751-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-22
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2026171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty