MEDICARE: DR. RENOLD J STATLER D.C.

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	001215	CT
2	111N00000X	Chiropractor	X008481-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10442835	OTHER	CT	CAQH
2	X7A852	OTHER	NY	PTAN

General Provider Information

NPI Number	:	1750357851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RENOLD J STATLER D.C.

Provider Business Mailing Address
First Line	:	519 S BROADWAY
Second Line	:
City	:	YONKERS
State	:	NY
Zip	:	10705-3256
Country	:	US
Telephone Number	:	914-963-7878
Fax Number	:	914-476-2225

Provider Business Practice Location Address
First Line	:	979 ROUTE 22 STE B
Second Line	:
City	:	BREWSTER
State	:	NY
Zip	:	10509-1526
Country	:	US
Telephone Number	:	845-279-4300
Fax Number	:	845-582-0293

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	12/18/2018

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