Provider Demographics
NPI:1356510374
Name:UPSTATE CHIROPRACTIC HEALTH CENTER
Entity Type:Organization
Organization Name:UPSTATE CHIROPRACTIC HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:CULLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-339-2422
Mailing Address - Street 1:117 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-5758
Mailing Address - Country:US
Mailing Address - Phone:315-339-2422
Mailing Address - Fax:315-338-0924
Practice Address - Street 1:117 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5758
Practice Address - Country:US
Practice Address - Phone:315-339-2422
Practice Address - Fax:315-338-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-24
Last Update Date:2008-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008342111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56189AOtherMEDICARE