Healthcare Provider Details

I. General information

NPI: 1730265463
Provider Name (Legal Business Name): DIANE JENAVE IWANIEC DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE JENAVE MACGAURN

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
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 NumberX005916
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001439
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: