Provider Demographics
NPI:1710397229
Name:ROBERTSON, KYLE (DC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ROBERTSON
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 1:22 WYCKOFF AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:WALDWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:07463-1788
Mailing Address - Country:US
Mailing Address - Phone:201-972-6121
Mailing Address - Fax:201-447-0827
Practice Address - Street 1:22 WYCKOFF AVE STE 1
Practice Address - Street 2:
Practice Address - City:WALDWICK
Practice Address - State:NJ
Practice Address - Zip Code:07463-1788
Practice Address - Country:US
Practice Address - Phone:201-972-6121
Practice Address - Fax:201-447-0827
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00716200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor