1245479435 NPI number — DRD HEALTHSOURCE CHIROPRACTIC PLLC

Table of content: (NPI 1245479435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245479435 NPI number — DRD HEALTHSOURCE CHIROPRACTIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRD HEALTHSOURCE CHIROPRACTIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HEALTHSOURCE CHIROPRACTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245479435
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 ERIE CANAL DR
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14626-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-225-6430
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 ERIE CANAL DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14626-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-225-6430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DUDLEY
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
585-225-6430

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  X009170 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106032AN . This is a "PREFERRED CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P010009170 . This is a "BLUE CHOICE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 647276 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7067356 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P020009170 . This is a "EXCELLUS BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: C09170-4 . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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