Provider Demographics
NPI:1336328228
Name:PROACTIVE CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:PROACTIVE CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:518-373-9999
Mailing Address - Street 1:1539 CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-7701
Mailing Address - Country:US
Mailing Address - Phone:518-373-9999
Mailing Address - Fax:518-373-8887
Practice Address - Street 1:1539 CRESCENT RD
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-7701
Practice Address - Country:US
Practice Address - Phone:518-373-9999
Practice Address - Fax:518-373-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009691111N00000X
NYX010445111N00000X
NYX008963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1408Medicare PIN
NYDD3127Medicare PIN
NYDD3126Medicare PIN