Provider Demographics
NPI:1942235221
Name:HERRITT, KENNETH EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:HERRITT
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 1:64 BOXWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHURCHVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18966-1013
Mailing Address - Country:US
Mailing Address - Phone:215-537-0774
Mailing Address - Fax:
Practice Address - Street 1:5204 TORRESDALE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2201
Practice Address - Country:US
Practice Address - Phone:215-537-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADCX003945L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012277250001Medicaid
PAU01404Medicare UPIN
PA0012277250001Medicaid