Healthcare Provider Details

I. General information

NPI: 1396016408
Provider Name (Legal Business Name): ELIZABETH ROSE HLADIK D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH ROSE FAVRO D.C

II. Dates (important events)

Enumeration Date: 01/20/2012
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HOMER AVE STE 1
QUEENSBURY NY
12804-2066
US

IV. Provider business mailing address

5 MC CREA RD
QUEENSBURY NY
12804-9183
US

V. Phone/Fax

Practice location:
  • Phone: 518-798-4322
  • Fax: 518-743-8686
Mailing address:
  • Phone: 518-335-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number012132
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: