Provider Demographics
NPI:1073712220
Name:PENN CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:PENN CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:MOLLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:412-751-4991
Mailing Address - Street 1:2606 LINCOLN WAY # A
Mailing Address - Street 2:
Mailing Address - City:MCKEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:15131-2831
Mailing Address - Country:US
Mailing Address - Phone:412-751-4991
Mailing Address - Fax:412-751-1484
Practice Address - Street 1:2606 LINCOLN WAY # A
Practice Address - Street 2:
Practice Address - City:MCKEESPORT
Practice Address - State:PA
Practice Address - Zip Code:15131-2831
Practice Address - Country:US
Practice Address - Phone:412-751-4991
Practice Address - Fax:412-751-1484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00072377OtherRAILROAD MEDICARE
PA1370703OtherHIGHMARK
PA1370703OtherHIGHMARK
PAU90486Medicare UPIN