MEDICARE: ADVANTAGE CHIROPRACTIC, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1053060558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE CHIROPRACTIC, PLLC

Provider Business Mailing Address
First Line	:	5945 COUNCIL ST NE STE B
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52402-5897
Country	:	US
Telephone Number	:	319-409-5941
Fax Number	:	319-409-5942

Provider Business Practice Location Address
First Line	:	5945 COUNCIL ST NE STE B
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52402-5897
Country	:	US
Telephone Number	:	319-409-5941
Fax Number	:	319-409-5942

Authorized Official
Title or Position	:	OWNER
Name	:	DR. NOLAN KENNEDY
Credential	:	DC
Telephone Number	:	319-409-5941

Provider Enumeration Date	:	03/22/2022
Last Update Date	:	03/29/2022

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