MEDICARE: BOEHLY CHIROPRACTIC, PLLC

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	X009295	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G0187432590	OTHER	NY	EXCELLUS BCBS GROUP ID #

General Provider Information

NPI Number	:	1215151832
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOEHLY CHIROPRACTIC, PLLC

Provider Business Mailing Address
First Line	:	3225 CHILI AVE
Second Line	:	SUITE #2
City	:	ROCHESTER
State	:	NY
Zip	:	14624-5442
Country	:	US
Telephone Number	:	585-889-7170
Fax Number	:	585-889-7178

Provider Business Practice Location Address
First Line	:	3225 CHILI AVE
Second Line	:	SUITE #2
City	:	ROCHESTER
State	:	NY
Zip	:	14624-5442
Country	:	US
Telephone Number	:	585-889-7170
Fax Number	:	585-889-7178

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES RICHARD BOEHLY
Credential	:	D.C.
Telephone Number	:	585-889-7170

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	12/28/2015

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