Provider Demographics
NPI:1871660860
Name:KETTERING, KAM DEMAR (DC)
Entity Type:Individual
Prefix:DR
First Name:KAM
Middle Name:DEMAR
Last Name:KETTERING
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 1:2285 WILLOW STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-4839
Mailing Address - Country:US
Mailing Address - Phone:717-464-0006
Mailing Address - Fax:717-464-1038
Practice Address - Street 1:2285 WILLOW STREET PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-4839
Practice Address - Country:US
Practice Address - Phone:717-464-0006
Practice Address - Fax:717-464-1038
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003259L111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA422164Medicare PIN