Healthcare Provider Details

I. General information

NPI: 1245479435
Provider Name (Legal Business Name): DRD HEALTHSOURCE CHIROPRACTIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 08/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 ERIE CANAL DR SUITE D
ROCHESTER NY
14626-4610
US

IV. Provider business mailing address

90 ERIE CANAL DR SUITE D
ROCHESTER NY
14626-4610
US

V. Phone/Fax

Practice location:
  • Phone: 585-225-6430
  • Fax:
Mailing address:
  • Phone: 585-225-6430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX009170
License Number StateNY

VIII. Authorized Official

Name: DR. DONALD R DUDLEY
Title or Position: CHIROPRACTOR
Credential: DC,CCSP
Phone: 585-225-6430