Provider Demographics
NPI:1013126507
Name:PARKER, KENNETH WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:PARKER
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 1:12628 CLARKSBURG TRL
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-1718
Mailing Address - Country:US
Mailing Address - Phone:817-379-6979
Mailing Address - Fax:
Practice Address - Street 1:12453 TIMBERLAND BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-5208
Practice Address - Country:US
Practice Address - Phone:817-431-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10541111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
613290Medicare PIN