=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164510913
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN HAMILTON DEGONZAGUE DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2006
-----------------------------------------------------
Last Update Date | 06/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 FULLER RD INNER BALANCE CHIROPRACTIC
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-3647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-482-2003
-----------------------------------------------------
Fax | 518-482-2087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 44 SWARTSON CT
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12209-1237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-489-0963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X009755-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------