Provider Demographics
NPI:1952368227
Name:PITKIN, KENNETH WAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
Last Name:PITKIN
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 1:101 W 2ND ST
Mailing Address - Street 2:STE 207
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3050
Mailing Address - Country:US
Mailing Address - Phone:815-288-7911
Mailing Address - Fax:815-288-6387
Practice Address - Street 1:101 W 2ND ST
Practice Address - Street 2:STE 150
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-288-7911
Practice Address - Fax:815-288-6387
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038007454111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL38007454Medicaid
IL05227552OtherBCBS
IL705870Medicare ID - Type Unspecified