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General NPI Number Information
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NPI Number | 1154718666
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Entity Type | Organization
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Legal Business Name | LIBERTY PARK CHIROPRACTIC, PC
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Dates
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Enumeration Date | 04/22/2015
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Last Update Date | 04/22/2015
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Provider Practice Location Address
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Address Line | 9316 LIBERTY AVE
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City | OZONE PARK
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State | NY
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Zip | 11417-1528
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Country | US
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Telephone | 718-764-6669
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Fax | 718-835-5505
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Provider Business Mailing Address
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Address Line | 9316 LIBERTY AVE
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City | OZONE PARK
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State | NY
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Zip | 11417-1528
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Country | US
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Telephone | 718-764-6669
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Fax | 718-835-5505
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Authorized Official
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Title or Position | PRES./OWNER
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Name | JOSEPH A CICCONE
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Credential | DC
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Telephone | 718-764-6669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | C09423-2
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License Number State | NY
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