Provider Demographics
NPI:1093019176
Name:VILLAGE CHIROPRACTIC SPORTS & FAMILY, PC
Entity Type:Organization
Organization Name:VILLAGE CHIROPRACTIC SPORTS & FAMILY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:F
Authorized Official - Last Name:LISJAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-257-5300
Mailing Address - Street 1:31 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CATTARAUGUS
Mailing Address - State:NY
Mailing Address - Zip Code:14719-1223
Mailing Address - Country:US
Mailing Address - Phone:716-257-5300
Mailing Address - Fax:716-257-1352
Practice Address - Street 1:31 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CATTARAUGUS
Practice Address - State:NY
Practice Address - Zip Code:14719-1223
Practice Address - Country:US
Practice Address - Phone:716-257-5300
Practice Address - Fax:716-257-1352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty