Provider Demographics
NPI:1285769828
Name:FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:FAMILY CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:FUNDARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-236-6177
Mailing Address - Street 1:1850-82 STREET
Mailing Address - Street 2:SUITE L-2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-2264
Mailing Address - Country:US
Mailing Address - Phone:718-236-6177
Mailing Address - Fax:718-236-6178
Practice Address - Street 1:1850-82 STREET
Practice Address - Street 2:SUITE L-2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2264
Practice Address - Country:US
Practice Address - Phone:718-236-6177
Practice Address - Fax:718-236-6178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX003524-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCO3524-8BOtherNYS WORKER'S COMPENSATION
NYU34247Medicare UPIN
NYX19391Medicare ID - Type Unspecified