Healthcare Provider Details

I. General information

NPI: 1306115407
Provider Name (Legal Business Name): DAVID R ROOT D C P T LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

338 CENTRAL AVE
DUNKIRK NY
14048-2100
US

IV. Provider business mailing address

338 CENTRAL AVE PO BOX 70
DUNKIRK NY
14048-2100
US

V. Phone/Fax

Practice location:
  • Phone: 716-366-2229
  • Fax: 716-366-7874
Mailing address:
  • Phone: 716-366-2229
  • Fax: 716-366-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5002477
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4983811
License Number StateNY

VIII. Authorized Official

Name: DAVID R ROOT DC PT
Title or Position: OWNER
Credential: DC PT
Phone: 716-366-2229