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General NPI Number Information
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NPI Number | 1699984088
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Entity Type | Organization
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Legal Business Name | KENNSTAR LLC
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 630 CHURCH ST NE
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City | MARIETTA
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State | GA
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Zip | 30060-1172
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Country | US
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Telephone | 770-428-4416
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Fax | 770-428-2693
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Provider Business Mailing Address
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Address Line | 630 CHURCH ST NE
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City | MARIETTA
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State | GA
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Zip | 30060-1172
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Country | US
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Telephone | 770-428-4416
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Fax | 770-428-2693
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Authorized Official
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Title or Position | MANAGER
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Name | ABNER F SALAS
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Credential |
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Telephone | 770-428-4416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIRO02616
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License Number State | GA
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