1114207123 NPI number — AMODEO CHIROPRACTIC CENTER PA

Table of content: (NPI 1114207123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114207123 NPI number — AMODEO CHIROPRACTIC CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMODEO CHIROPRACTIC CENTER PA
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:
6
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:
1114207123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLIERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38027-0726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-853-8270
Provider Business Mailing Address Fax Number:
901-854-5193

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 W POPLAR AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
COLLIERVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38017-2592
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-853-8270
Provider Business Practice Location Address Fax Number:
901-854-5193
Provider Enumeration Date:
08/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
AMODEO
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
901-853-8270

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  DC173 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6688660001 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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