Healthcare Provider Details

I. General information

NPI: 1003018680
Provider Name (Legal Business Name): KYLE A KNOELL DC, MHA, CCCSMP, CCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 BORDENTOWN AVE 4 FL, SUITE 4900
SOUTH AMBOY NJ
08879
US

IV. Provider business mailing address

PO BOX 61
EAST BRUNSWICK NJ
08816-0061
US

V. Phone/Fax

Practice location:
  • Phone: 732-721-3300
  • Fax: 732-721-3302
Mailing address:
  • Phone: 732-721-3300
  • Fax: 732-721-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00521600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00521600
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number38MC00521600
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number38MC00521600
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: