Provider Demographics
NPI:1760557466
Name:PERESTAM CHIROPRACTIC PC
Entity Type:Organization
Organization Name:PERESTAM CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:REED
Authorized Official - Last Name:PERESTAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-687-0800
Mailing Address - Street 1:1921 STATE ROUTE 17C
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827
Mailing Address - Country:US
Mailing Address - Phone:607-687-0800
Mailing Address - Fax:607-687-3942
Practice Address - Street 1:1921 STATE ROUTE 17C
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827
Practice Address - Country:US
Practice Address - Phone:607-687-0800
Practice Address - Fax:607-687-3942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0059261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB3336Medicare ID - Type Unspecified
U09804Medicare UPIN