Provider Demographics
NPI:1336241785
Name:THOMAS, KENNEDY HENRY (DC)
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:HENRY
Last Name:THOMAS
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 1:406 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MN
Mailing Address - Zip Code:56510
Mailing Address - Country:US
Mailing Address - Phone:218-784-2330
Mailing Address - Fax:218-784-2331
Practice Address - Street 1:406 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MN
Practice Address - Zip Code:56510
Practice Address - Country:US
Practice Address - Phone:218-784-2330
Practice Address - Fax:218-784-2331
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1429111N00000X
ND724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN680527200Medicaid
T66213Medicare UPIN
MN680527200Medicaid