Provider Demographics
NPI:1164757381
Name:PEQUEA VALLEY INTERNAL MEDICINE
Entity Type:Organization
Organization Name:PEQUEA VALLEY INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BENEDICT
Authorized Official - Middle Name:R
Authorized Official - Last Name:LACORTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-560-3505
Mailing Address - Street 1:1725 OREGON PIKE
Mailing Address - Street 2:107B
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4206
Mailing Address - Country:US
Mailing Address - Phone:717-560-3505
Mailing Address - Fax:717-560-3531
Practice Address - Street 1:1725 OREGON PIKE
Practice Address - Street 2:107B
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4206
Practice Address - Country:US
Practice Address - Phone:717-560-3505
Practice Address - Fax:717-560-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002045L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty