Provider Demographics
NPI:1003861907
Name:ADVANCED CHIROPRACTIC & REHAB, PC
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC & REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSTIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-898-8900
Mailing Address - Street 1:900B CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-1416
Mailing Address - Country:US
Mailing Address - Phone:717-898-8900
Mailing Address - Fax:717-898-6009
Practice Address - Street 1:900B CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-1416
Practice Address - Country:US
Practice Address - Phone:717-898-8900
Practice Address - Fax:717-898-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008781111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50003718OtherCAPITAL BLUE CROSS
PAP00231877OtherRAILROAD MEDICARE
PAAD1775455OtherHIGHMARK BLUE SHIELD
PA1190412OtherAETNA
PAAD1775455OtherHIGHMARK BLUE SHIELD
PA097230Medicare ID - Type Unspecified