Healthcare Provider Details

I. General information

NPI: 1881297364
Provider Name (Legal Business Name): ENISA LATIC DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 GENESEE ST
UTICA NY
13501-6222
US

IV. Provider business mailing address

2709 GENESEE ST
UTICA NY
13501-6222
US

V. Phone/Fax

Practice location:
  • Phone: 315-797-1908
  • Fax:
Mailing address:
  • Phone: 315-797-1908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number013433
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: