Provider Demographics
NPI:1952467722
Name:DECESARE CHIROPRACTIC OFFICE PC
Entity Type:Organization
Organization Name:DECESARE CHIROPRACTIC OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:DECASARE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:845-339-6000
Mailing Address - Street 1:572 ULSTER AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1924
Mailing Address - Country:US
Mailing Address - Phone:845-339-6000
Mailing Address - Fax:845-339-6065
Practice Address - Street 1:572 ULSTER AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1924
Practice Address - Country:US
Practice Address - Phone:845-339-6000
Practice Address - Fax:845-339-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004697111N00000X
NYX006381111N00000X
NYX008548111N00000X
X008697111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5803085OtherGHI
T53053Medicare UPIN
NYX28251Medicare ID - Type Unspecified