Provider Demographics
NPI:1770665903
Name:KOLWAITE, JAMES GREGORY (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
Last Name:KOLWAITE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13417-1481
Mailing Address - Country:US
Mailing Address - Phone:315-768-7578
Mailing Address - Fax:315-768-0929
Practice Address - Street 1:587 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW YORK MILLS
Practice Address - State:NY
Practice Address - Zip Code:13417-1481
Practice Address - Country:US
Practice Address - Phone:315-768-7578
Practice Address - Fax:315-768-0929
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0089351111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
C089351OtherWORKERS COMP
5899696OtherGHI
002932900OtherBCBS
3210OtherMVP
656379OtherACN
A7467OtherEMPRIE BC
3210OtherMVP
BB0785Medicare ID - Type Unspecified