Healthcare Provider Details

I. General information

NPI: 1457341901
Provider Name (Legal Business Name): ROBERT S KENNEKE D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 W EMPIRE ST
FREEPORT IL
61032-6100
US

IV. Provider business mailing address

1255 W EMPIRE ST
FREEPORT IL
61032-6100
US

V. Phone/Fax

Practice location:
  • Phone: 815-232-1100
  • Fax: 815-232-1100
Mailing address:
  • Phone: 815-232-1100
  • Fax: 815-232-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038007145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: