Provider Demographics
NPI:1124159413
Name:KENNEDY, AMY L (DC)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:L
Last Name:KENNEDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28924 S WESTERN AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0885
Mailing Address - Country:US
Mailing Address - Phone:310-831-8833
Mailing Address - Fax:310-831-8831
Practice Address - Street 1:28924 S WESTERN AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-0885
Practice Address - Country:US
Practice Address - Phone:310-831-8833
Practice Address - Fax:310-831-8831
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26747111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA800040509OtherTAX IDENTIFICATION NUMBER