=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669004313
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANACKER CHIROPRACTIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2020
-----------------------------------------------------
Last Update Date | 02/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 213 MAIN ST STE 106
-----------------------------------------------------
City | MASSENA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13662-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-705-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 MAIN ST STE 106
-----------------------------------------------------
City | MASSENA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13662-2905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-705-4410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER/PRESIDENT
-----------------------------------------------------
Name | DR. LUCAS VANACKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 315-705-4410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------