Provider Demographics
NPI:1871594192
Name:PORT CITY CHIROPRACTIC, PC
Entity type:Organization
Organization Name:PORT CITY CHIROPRACTIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:GALVIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:315-342-6151
Mailing Address - Street 1:11 FOURTH AVE
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1852
Mailing Address - Country:US
Mailing Address - Phone:315-342-6151
Mailing Address - Fax:315-342-8548
Practice Address - Street 1:11 FOURTH AVE
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1852
Practice Address - Country:US
Practice Address - Phone:315-342-6151
Practice Address - Fax:315-342-8548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005645-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY888021393OtherEXCELLUS BC/BS
NYRA6183Medicare ID - Type Unspecified
NY888021393OtherEXCELLUS BC/BS