Healthcare Provider Details

I. General information

NPI: 1154516557
Provider Name (Legal Business Name): CREEKSIDE CHIROPRACTIC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2007
Last Update Date: 09/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 WILLIAM ST
WHITEHALL NY
12887-1318
US

IV. Provider business mailing address

50 WILLIAM ST
WHITEHALL NY
12887-1318
US

V. Phone/Fax

Practice location:
  • Phone: 518-824-1225
  • Fax: 518-824-1244
Mailing address:
  • Phone: 518-824-1225
  • Fax: 518-824-1244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX-011003
License Number StateNY

VIII. Authorized Official

Name: DR. TOM GENSTIL
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 518-824-1225