Provider Demographics
NPI:1083622336
Name:TACKETT CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:TACKETT CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:518-798-4322
Mailing Address - Street 1:19 HOMER AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-2039
Mailing Address - Country:US
Mailing Address - Phone:518-798-4322
Mailing Address - Fax:518-743-8686
Practice Address - Street 1:19 HOMER AVE
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-2039
Practice Address - Country:US
Practice Address - Phone:518-798-4322
Practice Address - Fax:518-743-8686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008214111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8248OtherCDPHP
NY8248OtherCDPHP