MEDICARE: DR. WALTER F PRIESTLEY DC, DICCP

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	X005258-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	X005258-1	OTHER	NY	LICENSE NUMBER

General Provider Information

NPI Number	:	1700885670
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER F PRIESTLEY DC, DICCP

Provider Business Mailing Address
First Line	:	81 CONKLIN ST
Second Line	:
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-2555
Country	:	US
Telephone Number	:	516-752-1007
Fax Number	:	516-752-2767

Provider Business Practice Location Address
First Line	:	81 CONKLIN ST
Second Line	:
City	:	FARMINGDALE
State	:	NY
Zip	:	11735-2555
Country	:	US
Telephone Number	:	516-752-1007
Fax Number	:	516-752-2767

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	05/31/2012

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