Healthcare Provider Details

I. General information

NPI: 1205878808
Provider Name (Legal Business Name): EAST GREENBUSH CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 COLUMBIA TPKE
EAST GREENBUSH NY
12061-1600
US

IV. Provider business mailing address

568 COLUMBIA TPKE
EAST GREENBUSH NY
12061-1600
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-5000
  • Fax: 518-477-5009
Mailing address:
  • Phone: 518-477-5000
  • Fax: 518-477-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX007534-1
License Number StateNY

VIII. Authorized Official

Name: DR. TIMOTHY M KELLY
Title or Position: OWNER
Credential: D.C.
Phone: 518-477-5000