Provider Demographics
NPI:1851342992
Name:LANDRY, KENNETH (DC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LANDRY
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 1:546 ENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-2408
Mailing Address - Country:US
Mailing Address - Phone:860-265-3792
Mailing Address - Fax:
Practice Address - Street 1:546 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-2408
Practice Address - Country:US
Practice Address - Phone:860-265-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2225111N00000X
CT001461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY36882OtherBLUECROSS BLUESHIELD
MAY36882OtherBLUECROSS BLUESHIELD
MAY45534Medicare ID - Type UnspecifiedMEDICARE