Provider Demographics
NPI:1225010895
Name:DELRE, LAWRENCE (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:DELRE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 FAWCETT CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-1510
Mailing Address - Country:US
Mailing Address - Phone:412-260-8483
Mailing Address - Fax:412-542-1560
Practice Address - Street 1:109 FAWCETT CHURCH RD
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017
Practice Address - Country:US
Practice Address - Phone:412-260-8483
Practice Address - Fax:412-542-1560
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003005L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001642090OtherKEYSTONE/HIGHMARK
PA01012490Medicaid
PA11335917OtherCAQH (CREDENTIALING)
PAT29306Medicare UPIN
PA01012490Medicaid