Healthcare Provider Details

I. General information

NPI: 1396896148
Provider Name (Legal Business Name): KENNEDY CHIROPRACTIC HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MARKETPLACE DR SUITE 102
ROCKY MOUNT VA
24151-6516
US

IV. Provider business mailing address

5858 SALISBURY DR
ROANOKE VA
24018-4116
US

V. Phone/Fax

Practice location:
  • Phone: 540-483-3678
  • Fax: 540-483-3820
Mailing address:
  • Phone: 540-400-0036
  • Fax: 540-483-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number0104555747
License Number StateVA

VIII. Authorized Official

Name: DR. MIA M KENNEDY
Title or Position: OWNER
Credential: D.C.
Phone: 540-483-3678