Provider Demographics
NPI:1417009283
Name:WELLNESS SPORT & SPINE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:WELLNESS SPORT & SPINE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-786-3601
Mailing Address - Street 1:130 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1562
Mailing Address - Country:US
Mailing Address - Phone:607-786-3601
Mailing Address - Fax:607-834-7029
Practice Address - Street 1:130 FRONT ST
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-1562
Practice Address - Country:US
Practice Address - Phone:607-786-3601
Practice Address - Fax:607-834-7029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009961-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000143666OtherEXCELLUS BC BS
NY1003840711OtherNPI INDIVIDUAL
NY100651380167OtherCDPHP
NY5734880001OtherDMEPOS
NY648821OtherUNITED HEALTH CARE
NY100651380167OtherCDPHP