Provider Demographics
NPI:1538348792
Name:KIRK, KENNETH ROBERT (PT, ND)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:KIRK
Suffix:
Gender:M
Credentials:PT, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3214
Mailing Address - Country:US
Mailing Address - Phone:860-378-1234
Mailing Address - Fax:
Practice Address - Street 1:45 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3214
Practice Address - Country:US
Practice Address - Phone:860-378-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005244225100000X
CT000417175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080005244CT24OtherANTHEM