1215156070 NPI number — KENNETH E DEGROOT DC INC

Table of content: (NPI 1215156070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215156070 NPI number — KENNETH E DEGROOT DC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETH E DEGROOT DC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DE GROOT CHIROPRACTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215156070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1401 SILVERSIDE RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19810-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-475-5600
Provider Business Mailing Address Fax Number:
302-475-5940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 SILVERSIDE RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19810-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-475-5600
Provider Business Practice Location Address Fax Number:
302-475-5940
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DE GROOT
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
302-475-5600

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  F10000191 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0001073718 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2279331000 . This is a "AMERIHEALTH" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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