Healthcare Provider Details

I. General information

NPI: 1093834616
Provider Name (Legal Business Name): KENNETH STEPHEN WEINER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 ROSWELL RD
MARIETTA GA
30062-3621
US

IV. Provider business mailing address

1642 ROSWELL RD
MARIETTA GA
30062-3621
US

V. Phone/Fax

Practice location:
  • Phone: 770-973-8800
  • Fax: 770-971-6962
Mailing address:
  • Phone: 770-973-8800
  • Fax: 770-971-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number1048
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: