Provider Demographics
NPI:1639598741
Name:DODGE DELANCEY CHIROPRACTIC
Entity Type:Organization
Organization Name:DODGE DELANCEY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:GAEBEL
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-498-0243
Mailing Address - Street 1:8461 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:NY
Mailing Address - Zip Code:14551-9569
Mailing Address - Country:US
Mailing Address - Phone:315-498-0243
Mailing Address - Fax:315-498-0249
Practice Address - Street 1:8461 RIDGE RD
Practice Address - Street 2:
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9569
Practice Address - Country:US
Practice Address - Phone:315-498-0243
Practice Address - Fax:315-498-0249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70012414305R00000X
NY70012413305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1730514407Medicare NSC
NY1831524503Medicare NSC