Provider Demographics
NPI:1811046543
Name:EDWARDS, KENNETH GLENN (DC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GLENN
Last Name:EDWARDS
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 1:1602 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-3714
Mailing Address - Country:US
Mailing Address - Phone:334-297-2225
Mailing Address - Fax:334-480-9758
Practice Address - Street 1:1602 20TH AVE
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867-3714
Practice Address - Country:US
Practice Address - Phone:334-297-2225
Practice Address - Fax:334-480-9758
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL829111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor