Provider Demographics
NPI:1205016383
Name:OPTIMAL SPINE INC
Entity Type:Organization
Organization Name:OPTIMAL SPINE INC
Other - Org Name:ADIO CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAY-BRADLEY
Authorized Official - Last Name:WISTORT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-993-5388
Mailing Address - Street 1:32 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STEWARTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17363-4003
Mailing Address - Country:US
Mailing Address - Phone:717-993-5388
Mailing Address - Fax:717-993-5388
Practice Address - Street 1:32 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STEWARTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17363-4003
Practice Address - Country:US
Practice Address - Phone:717-993-5388
Practice Address - Fax:717-993-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC4408L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD52578001OtherCAREFIRST