Provider Demographics
NPI:1194976399
Name:INCLEDON CHIROPRACTIC LLC
Entity type:Organization
Organization Name:INCLEDON CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:INCLEDON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:845-897-2402
Mailing Address - Street 1:997 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1790
Mailing Address - Country:US
Mailing Address - Phone:845-897-2402
Mailing Address - Fax:845-897-2410
Practice Address - Street 1:997 MAIN ST
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1790
Practice Address - Country:US
Practice Address - Phone:845-897-2402
Practice Address - Fax:845-897-2410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX25901Medicare PIN