Provider Demographics
NPI:1558458208
Name:NORTHEN LIGHTS CHIROPRACTIC
Entity type:Organization
Organization Name:NORTHEN LIGHTS CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:V
Authorized Official - Last Name:SILVERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-782-7166
Mailing Address - Street 1:1116 ARSENAL STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-782-7166
Mailing Address - Fax:315-782-0978
Practice Address - Street 1:1116 ARSENAL STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-782-7166
Practice Address - Fax:315-782-0978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0025881111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T26512Medicare UPIN
NYAA1080Medicare ID - Type Unspecified