Provider Demographics
NPI:1093891350
Name:JOHN R DIMOND DC
Entity Type:Organization
Organization Name:JOHN R DIMOND DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-763-8000
Mailing Address - Street 1:OLD RTE 66 & HILL STREET
Mailing Address - Street 2:BOX 200
Mailing Address - City:MCGRANN
Mailing Address - State:PA
Mailing Address - Zip Code:16236
Mailing Address - Country:US
Mailing Address - Phone:724-763-8000
Mailing Address - Fax:
Practice Address - Street 1:OLD RTE 66 & HILL STREET
Practice Address - Street 2:# 200
Practice Address - City:MCGRANN
Practice Address - State:PA
Practice Address - Zip Code:16236
Practice Address - Country:US
Practice Address - Phone:724-763-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001391L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006346830002Medicaid
PA104161Medicare PIN