Healthcare Provider Details

I. General information

NPI: 1124107529
Provider Name (Legal Business Name): KENNETH MICHAEL DUDLEY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 W BUCHANAN ST STE 17
CALIFORNIA MO
65018-1238
US

IV. Provider business mailing address

1021 W BUCHANAN ST STE 17
CALIFORNIA MO
65018-1238
US

V. Phone/Fax

Practice location:
  • Phone: 573-796-8150
  • Fax: 573-796-8140
Mailing address:
  • Phone: 573-796-8150
  • Fax: 573-796-8140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number006298
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: