Provider Demographics
NPI:1629400668
Name:BACK TO BASICS CHIROPRACTIC
Entity Type:Organization
Organization Name:BACK TO BASICS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PUNTURIERO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-446-0048
Mailing Address - Street 1:3620 HARLEM RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14215-2042
Mailing Address - Country:US
Mailing Address - Phone:716-446-0048
Mailing Address - Fax:716-446-0411
Practice Address - Street 1:3620 HARLEM RD
Practice Address - Street 2:SUITE 1
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14215-2042
Practice Address - Country:US
Practice Address - Phone:716-446-0048
Practice Address - Fax:716-446-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-01
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010801-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA1014Medicare PIN