Provider Demographics
NPI:1750787586
Name:KENNEDY, TIMOTHY MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
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 1:318 SE FISK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-8920
Mailing Address - Country:US
Mailing Address - Phone:860-883-5850
Mailing Address - Fax:
Practice Address - Street 1:1680 SW SAINT LUCIE WEST BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986
Practice Address - Country:US
Practice Address - Phone:772-212-1111
Practice Address - Fax:772-212-0201
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor