Provider Demographics
NPI:1578917365
Name:ERTEL-REDFIELD, JUSTIN (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ERTEL-REDFIELD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 MAIN ST.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-616-9000
Mailing Address - Fax:716-408-3222
Practice Address - Street 1:8600 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7464
Practice Address - Country:US
Practice Address - Phone:716-616-9000
Practice Address - Fax:716-408-3222
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028258-1172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist