Healthcare Provider Details

I. General information

NPI: 1417048679
Provider Name (Legal Business Name): KENNETH P. SOULSBY D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 SOUTH GOLD AVE
DEMING NM
88030-4754
US

IV. Provider business mailing address

909 SOUTH GOLD AVE
DEMING NM
88030-4754
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-7331
  • Fax: 575-546-5380
Mailing address:
  • Phone: 575-546-7331
  • Fax: 575-546-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number839
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3800
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: