Provider Demographics
NPI:1821282930
Name:FLEETWOOD CHIROPRACTIC PC
Entity Type:Organization
Organization Name:FLEETWOOD CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:914-699-6770
Mailing Address - Street 1:25 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-2207
Mailing Address - Country:US
Mailing Address - Phone:914-699-6770
Mailing Address - Fax:914-664-0090
Practice Address - Street 1:25 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-2207
Practice Address - Country:US
Practice Address - Phone:914-699-6770
Practice Address - Fax:914-664-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002707C-1111N00000X
NYX004166-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty