Provider Demographics
NPI:1790022424
Name:KENMORE CHIROPRACTIC PC
Entity type:Organization
Organization Name:KENMORE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-873-0500
Mailing Address - Street 1:2839 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1330
Mailing Address - Country:US
Mailing Address - Phone:716-873-0500
Mailing Address - Fax:716-873-0500
Practice Address - Street 1:2839 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1330
Practice Address - Country:US
Practice Address - Phone:716-873-0500
Practice Address - Fax:716-873-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty