Healthcare Provider Details

I. General information

NPI: 1528013356
Provider Name (Legal Business Name): KENNETH WAYNE KILGORE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
WAUCHULA FL
33873-2819
US

IV. Provider business mailing address

4650 JOHNSTON RD
ZOLFO SPRINGS FL
33890-2799
US

V. Phone/Fax

Practice location:
  • Phone: 678-445-7055
  • Fax:
Mailing address:
  • Phone: 678-493-9765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number9100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: