Provider Demographics
NPI:1164539375
Name:CIESLAK, KENNETH T (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:T
Last Name:CIESLAK
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 1:12 OSBORNE TER
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-4362
Mailing Address - Country:US
Mailing Address - Phone:973-709-0574
Mailing Address - Fax:
Practice Address - Street 1:61 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOGOTA
Practice Address - State:NJ
Practice Address - Zip Code:07603-1369
Practice Address - Country:US
Practice Address - Phone:201-390-1816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00490000111N00000X
NJ25MT000333002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer