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General NPI Number Information
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NPI Number | 1366612400
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Entity Type | Organization
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Legal Business Name | BACK ON TRACK CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 03/05/2008
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Last Update Date | 01/10/2012
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Provider Practice Location Address
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Address Line | 8129 BREWERTON RD
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City | CICERO
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State | NY
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Zip | 13039
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Country | US
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Telephone | 315-699-9887
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Fax |
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Provider Business Mailing Address
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Address Line | 8129 BREWERTON RD
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City | CICERO
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State | NY
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Zip | 13039
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Country | US
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Telephone | 315-699-9887
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR/MEMBER
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Name | DR. KENNETH A ILES
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Credential | DC
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Telephone | 315-699-9887
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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 | X009391
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License Number State | NY
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