Provider Demographics
NPI:1831285360
Name:NIEBRUGGE, KENN ALLAN (DC)
Entity Type:Individual
Prefix:DR
First Name:KENN
Middle Name:ALLAN
Last Name:NIEBRUGGE
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 1:139 HOLDERRNESS DRIVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779
Mailing Address - Country:US
Mailing Address - Phone:407-682-5243
Mailing Address - Fax:407-682-5243
Practice Address - Street 1:4170 TOWN CENTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-5873
Practice Address - Country:US
Practice Address - Phone:407-857-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8610111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381757100Medicaid
FL381757100Medicaid