1093019176 NPI number — VILLAGE CHIROPRACTIC SPORTS & FAMILY, PC

Table of content: (NPI 1093019176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093019176 NPI number — VILLAGE CHIROPRACTIC SPORTS & FAMILY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VILLAGE CHIROPRACTIC SPORTS & FAMILY, PC
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:
1093019176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31 SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CATTARAUGUS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14719-1223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-257-5300
Provider Business Mailing Address Fax Number:
716-257-1352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CATTARAUGUS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14719-1223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-257-5300
Provider Business Practice Location Address Fax Number:
716-257-1352
Provider Enumeration Date:
01/04/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LISJAK
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
716-257-5300

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  X006035 , 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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