Provider Demographics
NPI:1255510616
Name:JOHN GRAHAM DC PC
Entity type:Organization
Organization Name:JOHN GRAHAM DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTOR
Authorized Official - Phone:518-371-5422
Mailing Address - Street 1:21 EXECUTIVE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-8651
Mailing Address - Country:US
Mailing Address - Phone:518-371-5422
Mailing Address - Fax:
Practice Address - Street 1:21 EXECUTIVE PARK DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-8651
Practice Address - Country:US
Practice Address - Phone:518-371-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX-2183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0789Medicare PIN