1598169674 NPI number — TWIN PINE FAMILY CHIROPRACTIC LLC

Table of content: (NPI 1598169674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598169674 NPI number — TWIN PINE FAMILY CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWIN PINE FAMILY CHIROPRACTIC LLC
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:
TWIN PINE FAMILY 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:
1598169674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
592 N GREEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRAKERS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12166-3202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-922-8624
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2609A STATE HIGHWAY 30A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONDA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12068-5955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-853-1567
Provider Business Practice Location Address Fax Number:
518-853-1609
Provider Enumeration Date:
10/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HULBERT
Authorized Official First Name:
SHARON
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
518-853-1567

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  X010120 , 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: P00104411 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: X6R72 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10057726 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 431905082-01 . This is a "BLUE SHIELD OF NORTHEAST" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: C10120-6B . This is a "WORKERS COMPENSATION" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: NY10120 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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