MEDICARE: KENNEDY CHIROPRACTIC PC

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	1536	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1285734335	OTHER	OR	INDIVIDUAL NPI NUMBER

General Provider Information

NPI Number	:	1982725719
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNEDY CHIROPRACTIC PC

Provider Business Mailing Address
First Line	:	155 B AVE
Second Line	:	SUITE 120
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3148
Country	:	US
Telephone Number	:	503-635-4558
Fax Number	:

Provider Business Practice Location Address
First Line	:	155 B AVE
Second Line	:	SUITE 120
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3148
Country	:	US
Telephone Number	:	503-635-4558
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL D KENNEDY
Credential	:	PC
Telephone Number	:	503-635-4558

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	08/22/2020

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