Provider Demographics
NPI:1801396353
Name:ANTIOQUIA CHIROPRACTIC P.C
Entity Type:Organization
Organization Name:ANTIOQUIA CHIROPRACTIC P.C
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:917-704-1978
Mailing Address - Street 1:7217 34TH AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1023
Mailing Address - Country:US
Mailing Address - Phone:917-704-1978
Mailing Address - Fax:
Practice Address - Street 1:11247 QUEENS BLVD STE 208
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7421
Practice Address - Country:US
Practice Address - Phone:718-544-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX-009105111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty