Healthcare Provider Details

I. General information

NPI: 1124145537
Provider Name (Legal Business Name): JASON D CICHOCKI CICHOPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 DICK RD
DEPEW NY
14043-1849
US

IV. Provider business mailing address

345 DICK RD
DEPEW NY
14043-1849
US

V. Phone/Fax

Practice location:
  • Phone: 716-681-3333
  • Fax: 716-681-3037
Mailing address:
  • Phone: 716-681-3333
  • Fax: 716-681-3037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX009547-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: