Provider Demographics
NPI:1245479435
Name:DRD HEALTHSOURCE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:DRD HEALTHSOURCE CHIROPRACTIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC,CCSP
Authorized Official - Phone:585-225-6430
Mailing Address - Street 1:90 ERIE CANAL DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4610
Mailing Address - Country:US
Mailing Address - Phone:585-225-6430
Mailing Address - Fax:
Practice Address - Street 1:90 ERIE CANAL DR
Practice Address - Street 2:SUITE D
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4610
Practice Address - Country:US
Practice Address - Phone:585-225-6430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009170111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
106032ANOtherPREFERRED CARE
NYP010009170OtherBLUE CHOICE
NY647276OtherUNITED HEALTHCARE
NY7067356OtherAETNA
NYP020009170OtherEXCELLUS BLUE CROSS/BLUE SHIELD
NYC09170-4OtherWORKERS COMPENSATION
NYC09170-4OtherWORKERS COMPENSATION