Healthcare Provider Details

I. General information

NPI: 1053497511
Provider Name (Legal Business Name): ROBERT JOSEPH IWANIEC DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 COLUMBIA TURNPIKE
RENSSELAER NY
12144
US

IV. Provider business mailing address

133 COLUMBIA TURNPIKE
RENSSELAER NY
12144
US

V. Phone/Fax

Practice location:
  • Phone: 518-432-7951
  • Fax: 518-432-7421
Mailing address:
  • Phone: 518-432-7951
  • Fax: 518-432-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX005647
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001440
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: