Provider Demographics
NPI:1932415130
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/ CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-929-0020
Mailing Address - Street 1:4155 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2403
Mailing Address - Country:US
Mailing Address - Phone:941-929-0020
Mailing Address - Fax:941-921-7843
Practice Address - Street 1:4155 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2403
Practice Address - Country:US
Practice Address - Phone:941-929-0020
Practice Address - Fax:941-921-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-25
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006233111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22563OtherMEDICARE PTAN / BCBS PROVIDER #
FL22563OtherMEDICARE PTAN / BCBS PROVIDER #