=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063672699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANCELLIERI CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2008
-----------------------------------------------------
Last Update Date | 06/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 WALT WHITMAN RD STE 100
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-673-6464
-----------------------------------------------------
Fax | 631-673-6488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 WALT WHITMAN RD STE 100
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANGELA M CANCELLIERI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 631-673-6464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X005472 1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------