Provider Demographics
NPI:1740370733
Name:BOSSBALY, RICHARD DICKRAN (CHIROPRACTOR)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DICKRAN
Last Name:BOSSBALY
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6419 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-1607
Mailing Address - Country:US
Mailing Address - Phone:201-854-3440
Mailing Address - Fax:201-854-0101
Practice Address - Street 1:6419 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1607
Practice Address - Country:US
Practice Address - Phone:201-854-3440
Practice Address - Fax:201-854-0101
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00131900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY226297469OtherGHI
NJ441350261OtherMEDICARERAILROAD
NJ168530901Medicaid
NJX56741OtherEMPIREBCBS
NJX56741OtherEMPIREBCBS