Provider Demographics
NPI:1588720338
Name:WYNANTSKILL CHIROPRACTIC PC
Entity type:Organization
Organization Name:WYNANTSKILL CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:518-286-3060
Mailing Address - Street 1:492 PAWLING AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-5834
Mailing Address - Country:US
Mailing Address - Phone:518-286-3060
Mailing Address - Fax:518-286-3044
Practice Address - Street 1:492 PAWLING AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5834
Practice Address - Country:US
Practice Address - Phone:518-286-3060
Practice Address - Fax:518-286-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2012-11-12
Deactivation Date:2008-07-28
Deactivation Code:
Reactivation Date:2010-10-08
Provider Licenses
StateLicense IDTaxonomies
NYX0066141111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10021222OtherCDPHP
X54101OtherBLUE CROSS BLUE SHIELD
NY607980OtherMVP
NYC066144OtherWORKERS' COMPENSATION
X54101OtherBLUE CROSS BLUE SHIELD