=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699594465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KRISTIN KUKENBERGER DBA KUKENBERGER CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 E GENESEE ST BLDG C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-314-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7000 E GENESEE ST BLDG C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-314-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KRISTIN KUKENBERGER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 315-314-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------