Provider Demographics
NPI:1689704330
Name:BRIAN C CARROLL DC PC
Entity Type:Organization
Organization Name:BRIAN C CARROLL DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:DC PC
Authorized Official - Phone:631-737-3838
Mailing Address - Street 1:PO BOX 167
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741
Mailing Address - Country:US
Mailing Address - Phone:631-737-3838
Mailing Address - Fax:631-737-8467
Practice Address - Street 1:1484 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741
Practice Address - Country:US
Practice Address - Phone:631-737-3838
Practice Address - Fax:631-737-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009401111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
X2C271Medicare ID - Type Unspecified