Provider Demographics
NPI:1457341901
Name:KENNEKE, ROBERT S (DC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:S
Last Name:KENNEKE
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 1:1255 W EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-6100
Mailing Address - Country:US
Mailing Address - Phone:815-232-1100
Mailing Address - Fax:815-232-1100
Practice Address - Street 1:1255 W EMPIRE ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6100
Practice Address - Country:US
Practice Address - Phone:815-232-1100
Practice Address - Fax:815-232-1100
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007145111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU48567Medicare UPIN
ILL96965Medicare ID - Type Unspecified