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General NPI Number Information
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NPI Number | 1184080608
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Entity Type | Organization
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Legal Business Name | CHILDRESS CHIROPRACTIC PC
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Dates
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Enumeration Date | 01/13/2016
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Last Update Date | 01/13/2016
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Provider Practice Location Address
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Address Line | 4317 E GENESEE ST SUITE 101
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City | DE WITT
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State | NY
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Zip | 13214-2114
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Country | US
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Telephone | 315-449-4465
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Fax | 315-449-4466
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Provider Business Mailing Address
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Address Line | 4317 E GENESEE ST SUITE 101
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City | DE WITT
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State | NY
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Zip | 13214-2114
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Country | US
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Telephone | 315-449-4465
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CODY CHILDRESS
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Credential | DC
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Telephone | 315-449-4465
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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 | X012698-1
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License Number State | NY
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