=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104948199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLAVITO CHIROPRACTIC PLLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2007
-----------------------------------------------------
Last Update Date | 05/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 453 ROUTE 211 E
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-344-1211
-----------------------------------------------------
Fax | 845-344-4045
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 453 ROUTE 211 E
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-344-1211
-----------------------------------------------------
Fax | 845-344-4045
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS A. COLAVITO
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 845-344-1211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X005219-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------