1396896148 NPI number — KENNEDY CHIROPRACTIC HEALTH CENTER

Table of content: (NPI 1396896148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396896148 NPI number — KENNEDY CHIROPRACTIC HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNEDY CHIROPRACTIC HEALTH CENTER
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:
Provider Other Organization Name Type Code:
6
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:
1396896148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5858 SALISBURY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24018-4116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-400-0036
Provider Business Mailing Address Fax Number:
540-483-3820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 MARKETPLACE DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
ROCKY MOUNT
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24151-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-483-3678
Provider Business Practice Location Address Fax Number:
540-483-3820
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KENNEDY
Authorized Official First Name:
MIA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
540-483-3678

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  0104555747 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 182483 . This is a "ANTHEM DRCOLLINS PROVIDER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 285308 . This is a "ANTHEM GROUP NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 317684 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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