Provider Demographics
NPI:1235396193
Name:TRINITY CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:TRINITY CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-469-9120
Mailing Address - Street 1:4583 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:JAMESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13078-9461
Mailing Address - Country:US
Mailing Address - Phone:315-469-9120
Mailing Address - Fax:315-469-9124
Practice Address - Street 1:4583 NORTH ST
Practice Address - Street 2:
Practice Address - City:JAMESVILLE
Practice Address - State:NY
Practice Address - Zip Code:13078-9461
Practice Address - Country:US
Practice Address - Phone:315-469-9120
Practice Address - Fax:315-469-9124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010412-2111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000144576OtherEXCELLUS BLUE CROSS BLUE SHIELD
AA1387Medicare UPIN