MEDICARE: DR. COLLEEN ANNE KENNEDY D.C.

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	111NN1001X	Nutrition Chiropractor	038004218	IL
2	111N00000X	Chiropractor	038004218	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02215206	OTHER	IL	BCBS
2	038004218	OTHER	IL	ILLINOIS LICENSE NUMBER

General Provider Information

NPI Number	:	1982767299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COLLEEN ANNE KENNEDY D.C.

Provider Business Mailing Address
First Line	:	1141 55TH ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4812
Country	:	US
Telephone Number	:	630-963-5029
Fax Number	:	630-297-8372

Provider Business Practice Location Address
First Line	:	1141 55TH ST
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4812
Country	:	US
Telephone Number	:	630-963-5029
Fax Number	:	630-297-8372

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	10/15/2023

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