=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487105847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KGS CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2016
-----------------------------------------------------
Last Update Date | 04/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 MAMARONECK AVE SUITE 105
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-686-8844
-----------------------------------------------------
Fax | 914-686-8842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 MAMARONECK AVENUE SUITE 105
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-686-8844
-----------------------------------------------------
Fax | 914-686-8842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KONSTANTINOS SOFOS
-----------------------------------------------------
Credential | CHIROPRACTIC
-----------------------------------------------------
Telephone | 914-686-8844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | XO113122
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------