Provider Demographics
NPI:1295983971
Name:DANIEL J KINKEAD PC
Entity type:Organization
Organization Name:DANIEL J KINKEAD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KINKEAD
Authorized Official - Suffix:
Authorized Official - Credentials:PC
Authorized Official - Phone:480-838-6696
Mailing Address - Street 1:3614 E SOUTHERN AVE
Mailing Address - Street 2:SUITE A-105
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2509
Mailing Address - Country:US
Mailing Address - Phone:480-838-6696
Mailing Address - Fax:480-838-9392
Practice Address - Street 1:3614 E SOUTHERN AVE
Practice Address - Street 2:SUITE A-105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2509
Practice Address - Country:US
Practice Address - Phone:480-838-6696
Practice Address - Fax:480-838-9392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ4294111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0004266286OtherAETNA PIN
AZAZ0932910OtherBCBS ID
AZ215276OtherCIGNA PROVIDER NUMBER
AZ0004266286OtherAETNA PIN