Provider Demographics
NPI:1053495135
Name:STACHACZ, MICHAEL A (DC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:A
Last Name:STACHACZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:PA
Mailing Address - Zip Code:18447
Mailing Address - Country:US
Mailing Address - Phone:570-489-6988
Mailing Address - Fax:570-383-5446
Practice Address - Street 1:135 MAIN ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447
Practice Address - Country:US
Practice Address - Phone:570-383-5446
Practice Address - Fax:570-383-5446
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004264L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAST593404Medicare ID - Type Unspecified
U01489Medicare UPIN