Provider Demographics
NPI:1700943560
Name:KENNEDY, KRIS K (DC)
Entity Type:Individual
Prefix:
First Name:KRIS
Middle Name:K
Last Name:KENNEDY
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 1:15520 ROCKFIELD BLVD
Mailing Address - Street 2:STE A200
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-6705
Mailing Address - Country:US
Mailing Address - Phone:949-598-9999
Mailing Address - Fax:949-598-9990
Practice Address - Street 1:11 MAREBLU
Practice Address - Street 2:120
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3066
Practice Address - Country:US
Practice Address - Phone:949-305-1790
Practice Address - Fax:949-305-1801
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC10783171100000X
CADC28686111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0286860OtherBLUE SHIELD
CADC28686Medicare ID - Type Unspecified
CADC0286860OtherBLUE SHIELD