Provider Demographics
NPI:1316143290
Name:KANTOR, JERRY MARTIN
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MARTIN
Last Name:KANTOR
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JERRY
Other - Middle Name:MARTIN
Other - Last Name:KANTOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LIC AC, MMHS
Mailing Address - Street 1:628 SOUTH ST
Mailing Address - Street 2:2
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1716
Mailing Address - Country:US
Mailing Address - Phone:617-327-3227
Mailing Address - Fax:
Practice Address - Street 1:332 WASHINGTON ST.
Practice Address - Street 2:VITAL FORCE HEALTH CARE, SUITE 380
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481
Practice Address - Country:US
Practice Address - Phone:781-431-1221
Practice Address - Fax:781-305-2077
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA143171100000X
175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered175L00000XOther Service ProvidersHomeopath