=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912462714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BINGHAMTON CHIROPRACTIC PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2019
-----------------------------------------------------
Last Update Date | 02/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 COURT ST STE G1
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13901-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-354-0985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 SOUTHSIDE DR
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13820-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-437-1795
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BENJAMIN COTTER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 607-354-0985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------