Provider Demographics
NPI:1124023114
Name:BRODHEADSVILLE CHIROPRACTIC
Entity Type:Organization
Organization Name:BRODHEADSVILLE CHIROPRACTIC
Other - Org Name:ROBERT J VAN METTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VAN METTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-992-7626
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:6 PILGRIM WAY
Mailing Address - City:BRODHEADSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18322-0447
Mailing Address - Country:US
Mailing Address - Phone:570-992-7626
Mailing Address - Fax:570-992-8759
Practice Address - Street 1:6 PILGRIM WAY
Practice Address - Street 2:
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-0447
Practice Address - Country:US
Practice Address - Phone:570-992-7626
Practice Address - Fax:570-992-8759
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRODHEADSVILLE CHIROPRACTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC1730L111N00000X
111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
712330Medicare PIN
PAT30201Medicare UPIN