Provider Demographics
NPI:1386960631
Name:OPTIMUM CHIROPRACTIC OF WESTERN NEW YORK, PLLC
Entity type:Organization
Organization Name:OPTIMUM CHIROPRACTIC OF WESTERN NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MONDSCHEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-833-1926
Mailing Address - Street 1:2875 UNION ROAD
Mailing Address - Street 2:SUITE 351
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-1461
Mailing Address - Country:US
Mailing Address - Phone:716-833-1926
Mailing Address - Fax:716-681-9456
Practice Address - Street 1:2875 UNION RD
Practice Address - Street 2:SUITE 351
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-1461
Practice Address - Country:US
Practice Address - Phone:716-833-1926
Practice Address - Fax:716-681-9456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011746111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty