Provider Demographics
NPI:1528158086
Name:VINCENT, BENJAMIN (DC)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
Last Name:VINCENT
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 1:1042 BARTLETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER JAY
Mailing Address - State:NY
Mailing Address - Zip Code:12987-3402
Mailing Address - Country:US
Mailing Address - Phone:518-946-2620
Mailing Address - Fax:
Practice Address - Street 1:13036 NYS RTE 9N
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:NY
Practice Address - Zip Code:12941
Practice Address - Country:US
Practice Address - Phone:518-946-7886
Practice Address - Fax:518-946-7367
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
RA6341Medicare ID - Type Unspecified
NYU96743Medicare UPIN