Provider Demographics
NPI:1134517683
Name:COLONIAL CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:COLONIAL CHIROPRACTIC, LLC
Other - Org Name:COLONIAL WELLNESS & REHABILITATION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:T
Authorized Official - Last Name:YACUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-328-1444
Mailing Address - Street 1:105 PENN MART SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4208
Mailing Address - Country:US
Mailing Address - Phone:302-328-1444
Mailing Address - Fax:302-328-1952
Practice Address - Street 1:105 PENN MART SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-4208
Practice Address - Country:US
Practice Address - Phone:302-328-1444
Practice Address - Fax:302-328-1952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEFL0000438111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
490056OtherMEDICARE ID - TYPE UNSPECIFIED
DEU55841Medicare UPIN