1730241738 NPI number — WAYNESBURG CHIROPRACTIC CLINIC, INC.

Table of content: (NPI 1730241738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730241738 NPI number — WAYNESBURG CHIROPRACTIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAYNESBURG CHIROPRACTIC CLINIC, 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:
1730241738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3157 MOUNT MORRIS RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WAYNESBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15370-8146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-627-9119
Provider Business Mailing Address Fax Number:
724-627-7598

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3157 MOUNT MORRIS RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WAYNESBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15370-8146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-627-9119
Provider Business Practice Location Address Fax Number:
724-627-7598
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JANSON
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
G
Authorized Official Title or Position:
SHAREHOLDER
Authorized Official Telephone Number:
724-627-9119

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC003477L , 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: 0011294570004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 70299 . This is a "UNISON" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1468554 . This is a "BCBS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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