Provider Demographics
NPI:1669563961
Name:VERNON, KENT DOUGLAS (DC)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:DOUGLAS
Last Name:VERNON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:492 CHARLENE LN
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-7858
Mailing Address - Country:US
Mailing Address - Phone:530-263-0473
Mailing Address - Fax:
Practice Address - Street 1:492 CHARLENE LN
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7858
Practice Address - Country:US
Practice Address - Phone:530-263-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC00204340Medicare ID - Type UnspecifiedCHIROPRACTIC