=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295058170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS G. BARBA D.C., CCSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2010
-----------------------------------------------------
Last Update Date | 03/08/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 RIDGE ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14092-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-754-9039
-----------------------------------------------------
Fax | 716-754-9064
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 RIDGE ST
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14092-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-754-9039
-----------------------------------------------------
Fax | 716-754-9064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number | X005933-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | X005933-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------