=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053418269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL DUDICK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 377 ROUTE 146
-----------------------------------------------------
City | CLIFTON PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12065-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-664-2673
-----------------------------------------------------
Fax | 518-664-2677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 ROUTE 146
-----------------------------------------------------
City | CLIFTON PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12065-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-664-2673
-----------------------------------------------------
Fax | 518-664-2677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CHIROPRACTOR
-----------------------------------------------------
Name | MICHAEL DUDICK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 518-664-2673
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 005172
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------