MEDICARE: MICHAEL J KENNEDY D.C., P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	4999	MN

General Provider Information

NPI Number	:	1518141027
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL J KENNEDY D.C., P.A.

Provider Business Mailing Address
First Line	:	12105 41ST AVE NORTH
Second Line	:	APT 118
City	:	PLYMOUTH
State	:	MN
Zip	:	55441
Country	:	US
Telephone Number	:	612-387-5864
Fax Number	:

Provider Business Practice Location Address
First Line	:	6409 CITY WEST PARKWAY
Second Line	:	SUITE 105
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344
Country	:	US
Telephone Number	:	952-833-3038
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/VICE-PRESIDENT/TREASURER
Name	:	DR. MICHAEL JOHN KENNEDY
Credential	:	D.C.
Telephone Number	:	612-387-5864

Provider Enumeration Date	:	12/19/2007
Last Update Date	:	12/19/2007

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