1629360805 NPI number — GENESIS CHIROPRACTIC PAIN MANAGEMENT P.C.

Table of content: DR. HALEIGH FYALL BROOKS DMD (NPI 1679316525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629360805 NPI number — GENESIS CHIROPRACTIC PAIN MANAGEMENT P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENESIS CHIROPRACTIC PAIN MANAGEMENT P.C.
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:
Provider Other Organization Name Type Code:
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:
1629360805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/20/2012
NPI Reactivation Date:
12/19/2012

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 703
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11561-0703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-581-2541
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
164 EAST PENN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-581-2541
Provider Business Practice Location Address Fax Number:
718-301-1804
Provider Enumeration Date:
05/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SUYNOV
Authorized Official First Name:
MAZAL
Authorized Official Middle Name:
JENNIFER
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
646-581-2541

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  X011936 , 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)





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