Provider Demographics
NPI:1700971587
Name:GOODMAN, KENNETH MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:GOODMAN
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 1:85 E STATE ROAD 73
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4823
Mailing Address - Country:US
Mailing Address - Phone:801-766-0507
Mailing Address - Fax:801-766-0838
Practice Address - Street 1:85 E STATE ROAD 73
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84043-4823
Practice Address - Country:US
Practice Address - Phone:801-766-0507
Practice Address - Fax:801-766-0838
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT349688-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT71957OtherPEHP
UT71957OtherPEHP