Provider Demographics
NPI:1629756515
Name:CUSTOM CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:CUSTOM CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-735-2125
Mailing Address - Street 1:813 WESTLAKE ST
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-2054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 E 14TH ST STE A
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14903-1339
Practice Address - Country:US
Practice Address - Phone:607-735-2125
Practice Address - Fax:607-735-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty