Provider Demographics
NPI:1003889536
Name:S. EAGLE RD CHIROPRACTIC INC
Entity Type:Organization
Organization Name:S. EAGLE RD CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-789-7669
Mailing Address - Street 1:31 S. EAGLE RD SUITE 101
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083
Mailing Address - Country:US
Mailing Address - Phone:610-789-7669
Mailing Address - Fax:610-789-7672
Practice Address - Street 1:31 S. EAGLE RD SUITE 101
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083
Practice Address - Country:US
Practice Address - Phone:610-789-7669
Practice Address - Fax:610-789-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-004701-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02592247Medicaid
PA02592247Medicaid
PAU40827Medicare UPIN