Provider Demographics
NPI:1598839904
Name:BIANCULLI, CHARLES R (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:BIANCULLI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 S WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURDT
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4908
Mailing Address - Country:US
Mailing Address - Phone:631-957-7733
Mailing Address - Fax:631-957-7734
Practice Address - Street 1:481 S WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURDT
Practice Address - State:NY
Practice Address - Zip Code:11757-4908
Practice Address - Country:US
Practice Address - Phone:631-957-7733
Practice Address - Fax:631-957-7734
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX2480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
X14521Medicare ID - Type Unspecified
T52115Medicare UPIN