Provider Demographics
NPI:1386292407
Name:SALLACH, MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SALLACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8178 STATE ROUTE 8
Mailing Address - Street 2:
Mailing Address - City:BRANT LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12815-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:23 FATHER JOGUES PL STE 1
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1407
Practice Address - Country:US
Practice Address - Phone:518-227-1323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-02
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013250-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty