Provider Demographics
NPI:1033249396
Name:REILLY, RICHARD (CA LAC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:CA LAC
Other - Prefix:DR
Other - First Name:RICHARD
Other - Middle Name:
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:70 PARK ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-5907
Mailing Address - Country:US
Mailing Address - Phone:973-744-8771
Mailing Address - Fax:
Practice Address - Street 1:70 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-5907
Practice Address - Country:US
Practice Address - Phone:973-744-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00146400111N00000X
NJ25MZ00008100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered171100000XOther Service ProvidersAcupuncturist