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General NPI Number Information
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NPI Number | 1417009283
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Entity Type | Organization
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Legal Business Name | WELLNESS SPORT & SPINE CHIROPRACTIC PLLC
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 06/17/2014
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Provider Practice Location Address
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Address Line | 130 FRONT ST
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City | VESTAL
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State | NY
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Zip | 13850-1562
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Country | US
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Telephone | 607-786-3601
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Fax | 607-834-7029
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Provider Business Mailing Address
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Address Line | 130 FRONT ST
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City | VESTAL
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State | NY
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Zip | 13850-1562
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Country | US
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Telephone | 607-786-3601
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Fax | 607-834-7029
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. KIM C MILLER
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Credential | DC
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Telephone | 607-786-3601
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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 | X009961-1
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License Number State | NY
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