Provider Demographics
NPI:1740476712
Name:ANTHONY V. LICATESE , DC, P.C.
Entity type:Organization
Organization Name:ANTHONY V. LICATESE , DC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:LICATESE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:315-342-6300
Mailing Address - Street 1:55 E BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2120
Mailing Address - Country:US
Mailing Address - Phone:315-342-6300
Mailing Address - Fax:315-342-6302
Practice Address - Street 1:55 E BRIDGE ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2120
Practice Address - Country:US
Practice Address - Phone:315-342-6300
Practice Address - Fax:315-342-6302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010996-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA 0440Medicare PIN