Provider Demographics
NPI:1528423944
Name:CANCELLIERI, CHARLES JOSEPH (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOSEPH
Last Name:CANCELLIERI
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 1:900 WALT WHITMAN ROAD (SUITE 100)
Mailing Address - Street 2:(SUITE 100)
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747
Mailing Address - Country:US
Mailing Address - Phone:631-673-6464
Mailing Address - Fax:631-673-6488
Practice Address - Street 1:900 WALT WHITMAN ROAD
Practice Address - Street 2:(SUITE 100)
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747
Practice Address - Country:US
Practice Address - Phone:631-673-6464
Practice Address - Fax:631-673-6488
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX00468-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor