Provider Demographics
NPI:1114029303
Name:MINIACI, KEITH A (DC)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:A
Last Name:MINIACI
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 1:111 SUNRISE HILL CIR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-1132
Mailing Address - Country:US
Mailing Address - Phone:203-469-5210
Mailing Address - Fax:203-468-8598
Practice Address - Street 1:53 HIGH ST
Practice Address - Street 2:
Practice Address - City:EAST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06512-2315
Practice Address - Country:US
Practice Address - Phone:203-469-5210
Practice Address - Fax:203-468-8598
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004128725Medicaid
050000410CT05OtherANTHEM BCS
CT004128725Medicaid
T22843Medicare UPIN