Provider Demographics
NPI:1134133846
Name:DEMAREST, KENNETH (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
Last Name:DEMAREST
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 1:740 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-2314
Mailing Address - Country:US
Mailing Address - Phone:860-296-0090
Mailing Address - Fax:860-296-1520
Practice Address - Street 1:740 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-2314
Practice Address - Country:US
Practice Address - Phone:860-296-0090
Practice Address - Fax:860-296-1520
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT10450156OtherCAQH
CT7163301OtherAETNA NON HMO/PPO#
CTCT0847OtherLANDMARK/HEALTH NET
CT050001360CT04OtherBCBS
CT1289267OtherAETNA HMO#
CT1034337OtherASHN
CT001360OtherSTATE LICENSE #
CTU80659Medicare UPIN