1396918215 NPI number — CONNEAUT LAKE CHIROPRACTIC, PC

Table of content: (NPI 1396918215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396918215 NPI number — CONNEAUT LAKE CHIROPRACTIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNEAUT LAKE CHIROPRACTIC, 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:
1396918215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13245 CONNEAUT LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONNEAUT LAKE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16316-6809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-382-8840
Provider Business Mailing Address Fax Number:
814-382-8840

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13245 CONNEAUT LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONNEAUT LAKE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16316-6809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-382-8840
Provider Business Practice Location Address Fax Number:
814-382-8840
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KEYSER
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
814-382-8840

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC007703L , 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: 340625 . This is a "HIGHMARK BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017865180003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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