Provider Demographics
NPI:1932161205
Name:TRUSSELL, KENNETH WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:TRUSSELL
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 1:113 W ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5111
Mailing Address - Country:US
Mailing Address - Phone:813-685-4222
Mailing Address - Fax:813-689-3832
Practice Address - Street 1:113 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5111
Practice Address - Country:US
Practice Address - Phone:813-685-4222
Practice Address - Fax:813-689-3832
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH006246111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380122500Medicaid
FL01781Medicare UPIN
FL22523Medicare ID - Type Unspecified