1629128772 NPI number — PORTAGE CHIROPRACTIC, P.C.

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 1629128772 NPI number — PORTAGE CHIROPRACTIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORTAGE 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:
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:
1629128772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 CALDWELL AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PORTAGE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15946-1571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-736-9897
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 CALDWELL AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15946-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-736-9897
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HERALD
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
814-736-9897

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC006906R , 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: 001455340 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 303267 . This is a "UPMC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0016403170004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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