Healthcare Provider Details

I. General information

NPI: 1790283182
Provider Name (Legal Business Name): MALTA CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 BLACKSMITH DR STE 1
BALLSTON SPA NY
12020-4428
US

IV. Provider business mailing address

10 BLACKSMITH DR STE 1
BALLSTON SPA NY
12020-4428
US

V. Phone/Fax

Practice location:
  • Phone: 518-289-5229
  • Fax:
Mailing address:
  • Phone: 518-289-5229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX012859-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberX006175-1
License Number StateNY

VIII. Authorized Official

Name: DR. WAQAS PERVAIZ
Title or Position: CHIROPRACTOR
Credential: DC
Phone: 518-289-5229