Provider Demographics
NPI:1457548018
Name:KEYSTONE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:KEYSTONE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:B
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-675-1644
Mailing Address - Street 1:410 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3147
Mailing Address - Country:US
Mailing Address - Phone:203-675-1644
Mailing Address - Fax:203-281-4466
Practice Address - Street 1:410 STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-3147
Practice Address - Country:US
Practice Address - Phone:203-675-1644
Practice Address - Fax:203-281-4466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001570111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
350001329Medicare PIN