1336175918 NPI number — WALCOTT CHIROPRACTIC, P.C.

Table of content: (NPI 1336175918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336175918 NPI number — WALCOTT CHIROPRACTIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALCOTT CHIROPRACTIC, P.C.
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:
1336175918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1548 REVERE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YARDLEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19067-4351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-493-1590
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14260 BUSTLETON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19116-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-676-0104
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WALCOTT
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
VAILL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-493-1590

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC007908L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2125718000 . This is a "PERSONAL CHOICE GROUP ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2125718000 . This is a "KEYSTONE GROUP ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 3063269 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 7979272 . This is a "AETNA TRADITIONAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0060935000 . This is a "AMERIHEALTH PIN ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 056172 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00240657 . This is a "RR MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1437125 . This is a "BLUE SHIELD GROUP ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: DD6376 . This is a "RR MEDICARE GROUP ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0060935000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0060935000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2192178 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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