Provider Demographics
NPI:1689699753
Name:CORALLO, CHARLES S (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:CORALLO
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 1:191 RAMAPO VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-2509
Mailing Address - Country:US
Mailing Address - Phone:201-651-0051
Mailing Address - Fax:201-651-0064
Practice Address - Street 1:191 RAMAPO VALLEY RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-2509
Practice Address - Country:US
Practice Address - Phone:201-651-0051
Practice Address - Fax:201-651-0064
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC001845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6428509Medicaid
NJ6428509Medicaid
NJ453448Medicare PIN