Provider Demographics
NPI:1982060091
Name:WADE, KEITH GARRETT (DC)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:GARRETT
Last Name:WADE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:362 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4950
Practice Address - Country:US
Practice Address - Phone:508-584-6622
Practice Address - Fax:508-584-7744
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2031111N00000X
MA3623111N00000X
NY012786111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor