1548349442 NPI number — LAVALETTE CHIROPRACTIC INC

Table of content: (NPI 1548349442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548349442 NPI number — LAVALETTE CHIROPRACTIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAVALETTE CHIROPRACTIC INC
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:
1548349442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1177
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAVALETTE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25535-1177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-522-7246
Provider Business Mailing Address Fax Number:
304-522-0018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4600A ROUTE 152
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVALETTE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-522-7246
Provider Business Practice Location Address Fax Number:
304-522-0018
Provider Enumeration Date:
11/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRY
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
SAMUEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
304-522-7246

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  691 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1066162 . This is a "WV WORKERS COMP VENDOR" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00195054 . This is a "MEDICARE RAILROAD CARRIER" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7600032000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001720189 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1841233806 . This is a "NPI FOR JOHN FRY, DC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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