=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659717411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOFOS CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2013
-----------------------------------------------------
Last Update Date | 08/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 MAMARONECK AVE 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 AVE 105
-----------------------------------------------------
City | WHITE PLAINS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10605-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-686-8844
-----------------------------------------------------
Fax | 914-686-8842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KONSTANTINOS G SOFOS
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 914-686-8844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X011312-2
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------