Healthcare Provider Details

I. General information

NPI: 1811685548
Provider Name (Legal Business Name): JESSE CHARLES BUMBARGER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 05/01/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24002 65TH AVE
DOUGLASTON NY
11362-1921
US

IV. Provider business mailing address

24002 65TH AVE
DOUGLASTON NY
11362-1921
US

V. Phone/Fax

Practice location:
  • Phone: 814-553-9784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX013612-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: