=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508596289
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA PRITTY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2022
-----------------------------------------------------
Last Update Date | 06/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 FORT HILL AVE
-----------------------------------------------------
City | CANANDAIGUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14424-1159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-393-8316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 DOWN ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14623-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-259-9166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X013452-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------