Provider Demographics
NPI:1255412151
Name:ECKHARDT, KENNETH LE ROY (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LE ROY
Last Name:ECKHARDT
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 1:400 ROWLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4617
Mailing Address - Country:US
Mailing Address - Phone:415-892-2212
Mailing Address - Fax:415-892-9458
Practice Address - Street 1:7100 REDWOOD BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-4110
Practice Address - Country:US
Practice Address - Phone:415-892-2212
Practice Address - Fax:415-892-9458
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19439111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC19439Medicare ID - Type UnspecifiedMEDICARE NUMBER