=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396896148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNEDY CHIROPRACTIC HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 MARKETPLACE DR SUITE 102
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24151-6516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-483-3678
-----------------------------------------------------
Fax | 540-483-3820
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5858 SALISBURY DR
-----------------------------------------------------
City | ROANOKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24018-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-400-0036
-----------------------------------------------------
Fax | 540-483-3820
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIA M KENNEDY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 540-483-3678
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 0104555747
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------