Provider Demographics
NPI:1003091448
Name:KETOLA, EINO WILLIAM (DC)
Entity Type:Individual
Prefix:
First Name:EINO
Middle Name:WILLIAM
Last Name:KETOLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 N SHORE DR
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:MA
Mailing Address - Zip Code:01775-1561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-2561
Practice Address - Country:US
Practice Address - Phone:508-765-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2524111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY45414Medicare PIN