MEDICARE: SACKETS HARBOR CHIROPRACTIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	X007976	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5805783	OTHER	NY	GHI
2	P01000796	OTHER	NY	BLUECROSS
3	98L1470	OTHER	NY	MVP

General Provider Information

NPI Number	:	1205051158
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACKETS HARBOR CHIROPRACTIC

Provider Business Mailing Address
First Line	:	107 BARRACKS DR
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-9530
Country	:	US
Telephone Number	:	315-646-3777
Fax Number	:	315-646-3890

Provider Business Practice Location Address
First Line	:	107 BARRACKS DR
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-9530
Country	:	US
Telephone Number	:	315-646-3777
Fax Number	:	315-646-3890

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MAGGIE CADDEN
Credential	:	MS
Telephone Number	:	315-646-3777

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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