Provider Demographics
NPI:1174508170
Name:DUTCH FORK CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:DUTCH FORK CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MILANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-732-3996
Mailing Address - Street 1:7839 BROAD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2357
Mailing Address - Country:US
Mailing Address - Phone:803-732-3996
Mailing Address - Fax:803-407-0081
Practice Address - Street 1:7839 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2357
Practice Address - Country:US
Practice Address - Phone:803-732-3996
Practice Address - Fax:803-407-0081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1953111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH432Medicaid