Provider Demographics
NPI:1932283405
Name:SAN ANGELO, SCOTT RICHARD (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:SAN ANGELO
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:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:FALCONER
Mailing Address - State:NY
Mailing Address - Zip Code:14733-0415
Mailing Address - Country:US
Mailing Address - Phone:716-665-5563
Mailing Address - Fax:716-665-5564
Practice Address - Street 1:220W MAIN ST
Practice Address - Street 2:
Practice Address - City:FALCONER
Practice Address - State:NY
Practice Address - Zip Code:14733-1616
Practice Address - Country:US
Practice Address - Phone:716-665-5563
Practice Address - Fax:716-665-5564
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-3724742-01OtherPRISM HEALTH NETWORK
NYC10929-0BOtherWORKER'S COMPENSATION
NY8812699OtherINDEPENDENT HEALTH
NY11-3724742-01OtherPRISM HEALTH NETWORK
V01129Medicare UPIN
NYC10929-0BOtherWORKER'S COMPENSATION