Provider Demographics
NPI:1164615399
Name:PORT JERVIS CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:PORT JERVIS CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:845-858-8000
Mailing Address - Street 1:27 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-1924
Mailing Address - Country:US
Mailing Address - Phone:845-858-8000
Mailing Address - Fax:845-858-8006
Practice Address - Street 1:27 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1924
Practice Address - Country:US
Practice Address - Phone:845-858-8000
Practice Address - Fax:845-858-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU99570Medicare UPIN
NYWXY001Medicare PIN