1174719272 NPI number — DIANA CHIROPRACTIC CENTER, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174719272 NPI number — DIANA CHIROPRACTIC CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIANA CHIROPRACTIC CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174719272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1056 GRANT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLETON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18202-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-455-8141
Provider Business Mailing Address Fax Number:
570-455-8153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1056 GRANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZLETON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18202-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-455-8141
Provider Business Practice Location Address Fax Number:
570-455-8153
Provider Enumeration Date:
09/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DIANA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
570-455-8141

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 130905 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017511560001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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