Healthcare Provider Details

I. General information

NPI: 1699771667
Provider Name (Legal Business Name): KEITH OCONNELL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 CRESCENT AVE STE B
WALDWICK NJ
07463-1400
US

IV. Provider business mailing address

61 CRESCENT AVE STE B
WALDWICK NJ
07463-1400
US

V. Phone/Fax

Practice location:
  • Phone: 201-444-1988
  • Fax: 201-444-8709
Mailing address:
  • Phone: 201-444-1988
  • Fax: 201-444-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00268600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: