Provider Demographics
NPI:1487798591
Name:BAYSIDE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:BAYSIDE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:718-279-9485
Mailing Address - Street 1:21015 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3239
Mailing Address - Country:US
Mailing Address - Phone:718-279-9485
Mailing Address - Fax:718-279-0986
Practice Address - Street 1:21015 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3239
Practice Address - Country:US
Practice Address - Phone:718-279-9485
Practice Address - Fax:718-279-0986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002968-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBAZ0S306Y10OtherBCBS
NYBAZ0S306Y10OtherBCBS
NY08172GMedicare PIN