Provider Demographics
NPI:1982207155
Name:COUNTRYSIDE FAMILY CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:COUNTRYSIDE FAMILY CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LASKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:585-449-9874
Mailing Address - Street 1:4385 RECREATION DR
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2232
Mailing Address - Country:US
Mailing Address - Phone:585-449-9874
Mailing Address - Fax:
Practice Address - Street 1:4385 RECREATION DR
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2232
Practice Address - Country:US
Practice Address - Phone:585-449-9874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013371OtherSTATE LICENSE