Healthcare Provider Details

I. General information

NPI: 1518102763
Provider Name (Legal Business Name): KJC CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 BROADWAY
LYNBROOK NY
11563-3243
US

IV. Provider business mailing address

255 BROADWAY
LYNBROOK NY
11563-3243
US

V. Phone/Fax

Practice location:
  • Phone: 516-341-7706
  • Fax: 516-341-7708
Mailing address:
  • Phone: 516-341-7706
  • Fax: 516-341-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX011421
License Number StateNY

VIII. Authorized Official

Name: DR. KENTIA JEAN-CHARLES
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 516-341-7706