=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083836688
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELMAR CHIROPRACTIC OFFICE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 12/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 DELAWARE AVENUE
-----------------------------------------------------
City | DELMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-439-7644
-----------------------------------------------------
Fax | 518-439-0191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 DELAWARE AVENUE
-----------------------------------------------------
City | DELMAR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-439-7644
-----------------------------------------------------
Fax | 518-439-0191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIMOTHY DAVID TALMAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-439-7644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X3627
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------