Provider Demographics
NPI:1609813898
Name:CONNERLY, JOHN CHRISTOPHER (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHRISTOPHER
Last Name:CONNERLY
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 1:1892 PLAZA DEL SUR DR STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6073
Mailing Address - Country:US
Mailing Address - Phone:505-988-8017
Mailing Address - Fax:505-988-8018
Practice Address - Street 1:1892 PLAZA DEL SUR DR STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6073
Practice Address - Country:US
Practice Address - Phone:505-988-8017
Practice Address - Fax:505-988-8018
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1314111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1314OtherSTATE LICENSE NUMBER
NM1314OtherSTATE LICENSE NUMBER
NM349524301Medicare PIN
NM900521238Medicare ID - Type UnspecifiedGROUP NUMBER