=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871867457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DARGOUT FAMILY CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2012
-----------------------------------------------------
Last Update Date | 02/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 728 WEILAND RD
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-705-8322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3018 N GENESEE ST
-----------------------------------------------------
City | GENEVA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14456-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHRISTINE MARIE DARGOUT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 585-705-8322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | X012122
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------