Provider Demographics
NPI:1881943900
Name:KENNEDY CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:KENNEDY CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:601-824-4217
Mailing Address - Street 1:393 CROSSGATES BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042
Mailing Address - Country:US
Mailing Address - Phone:601-824-4217
Mailing Address - Fax:601-824-4218
Practice Address - Street 1:393 CROSSGATES BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042
Practice Address - Country:US
Practice Address - Phone:601-824-4217
Practice Address - Fax:601-824-4218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS947111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSU67878Medicare UPIN