Provider Demographics
NPI:1871774489
Name:KENEMUTH FAMILY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:KENEMUTH FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KENEMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-768-8005
Mailing Address - Street 1:1520 S BABCOCK ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3034
Mailing Address - Country:US
Mailing Address - Phone:321-768-8005
Mailing Address - Fax:321-768-8726
Practice Address - Street 1:1520 S BABCOCK ST
Practice Address - Street 2:SUITE B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3034
Practice Address - Country:US
Practice Address - Phone:321-768-8005
Practice Address - Fax:321-768-8726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
70209Medicare UPIN