=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871742353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETER MARTIN CHIROPRACTIC OFFICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2008
-----------------------------------------------------
Last Update Date | 07/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10620 SHORE FRONT PKWY SUITE 12H
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-268-4316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10620 SHORE FRONT PKWY APT 12H
-----------------------------------------------------
City | ROCKAWAY PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11694-2639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-268-4316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PETER MARTIN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 929-268-4316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------