Healthcare Provider Details

I. General information

NPI: 1841494077
Provider Name (Legal Business Name): KENNETH LAYNE BERRY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 W TOWN PL STE. 118
ST AUGUSTINE FL
32092-3661
US

IV. Provider business mailing address

425 W TOWN PL STE. 118
ST AUGUSTINE FL
32092-3661
US

V. Phone/Fax

Practice location:
  • Phone: 904-940-0361
  • Fax: 904-940-0364
Mailing address:
  • Phone: 904-940-0361
  • Fax: 904-940-0364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9346
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: