Healthcare Provider Details

I. General information

NPI: 1417618596
Provider Name (Legal Business Name): MARK A KENNINGTON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2021
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 W PACIFIC ST STE C
BLACKFOOT ID
83221-1723
US

IV. Provider business mailing address

246 W PACIFIC ST STE C
BLACKFOOT ID
83221-1723
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-1113
  • Fax:
Mailing address:
  • Phone: 208-557-1113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-2344
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: