Provider Demographics
NPI:1871921015
Name:KEITH J O'CONNELL D.C.
Entity type:Organization
Organization Name:KEITH J O'CONNELL D.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:201-444-1988
Mailing Address - Street 1:61 CRESCENT AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463
Mailing Address - Country:US
Mailing Address - Phone:201-444-1988
Mailing Address - Fax:201-444-8709
Practice Address - Street 1:61 CRESCENT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-1431
Practice Address - Country:US
Practice Address - Phone:201-444-1988
Practice Address - Fax:201-444-8709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00268600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5231400Medicaid
NJ5231400Medicaid