Provider Demographics
NPI:1376700542
Name:OPTIMUM CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:OPTIMUM CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:IMPAGLIA
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:716-608-7075
Mailing Address - Street 1:4721 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043
Mailing Address - Country:US
Mailing Address - Phone:716-608-7078
Mailing Address - Fax:716-668-0606
Practice Address - Street 1:4721 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043
Practice Address - Country:US
Practice Address - Phone:716-608-7078
Practice Address - Fax:716-668-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC7062Medicare PIN