Provider Demographics
NPI:1932130614
Name:KENEMUTH, MICHAEL DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:KENEMUTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1520 S BABCOCK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3034
Mailing Address - Country:US
Mailing Address - Phone:321-768-8005
Mailing Address - Fax:321-768-8726
Practice Address - Street 1:1710 BRYAN STREET
Practice Address - Street 2:UNIT 1
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3034
Practice Address - Country:US
Practice Address - Phone:321-768-8005
Practice Address - Fax:321-768-8726
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL331040077OtherTAX ID
FL70290Medicare UPIN