Provider Demographics
NPI:1750357851
Name:STATLER, RENOLD J (DC)
Entity type:Individual
Prefix:DR
First Name:RENOLD
Middle Name:J
Last Name:STATLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:RENNIE
Other - Middle Name:J
Other - Last Name:STATLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:519 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-3256
Mailing Address - Country:US
Mailing Address - Phone:914-963-7878
Mailing Address - Fax:914-476-2225
Practice Address - Street 1:979 ROUTE 22 STE B
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-1526
Practice Address - Country:US
Practice Address - Phone:845-279-4300
Practice Address - Fax:845-582-0293
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001215111N00000X
NYX008481-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT10442835OtherCAQH
NYX7A852OtherPTAN
CT10442835OtherCAQH
CT350001073Medicare PIN