Provider Demographics
NPI:1548849094
Name:REVILLE, JOSEPH CONNOR (DC)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CONNOR
Last Name:REVILLE
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 1:91 S WASHINGTON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2242
Mailing Address - Country:US
Mailing Address - Phone:716-560-6718
Mailing Address - Fax:
Practice Address - Street 1:309 EXCHANGE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-2708
Practice Address - Country:US
Practice Address - Phone:585-454-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty