Provider Demographics
NPI:1184762221
Name:BERTHIAUME, KENNETH PAUL (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAUL
Last Name:BERTHIAUME
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 1:3 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:GREENLAND
Mailing Address - State:NH
Mailing Address - Zip Code:03840-2322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:GREENLAND
Practice Address - State:NH
Practice Address - Zip Code:03840-2322
Practice Address - Country:US
Practice Address - Phone:603-422-0432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MABE905111N00000X
NH997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MABEY35654OtherBLUE SHIELD
MABEY35654Medicare ID - Type Unspecified