Provider Demographics
NPI:1235780909
Name:ENNIS STRAIGHT CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:ENNIS STRAIGHT CHIROPRACTIC CENTER
Other - Org Name:BRADLEY D. ENNIS,DC
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-404-4046
Mailing Address - Street 1:1526 N ATHERTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-3041
Mailing Address - Country:US
Mailing Address - Phone:814-353-1217
Mailing Address - Fax:412-291-3381
Practice Address - Street 1:1526 N ATHERTON ST STE 200
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-3041
Practice Address - Country:US
Practice Address - Phone:814-237-5220
Practice Address - Fax:412-291-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-24
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA347952OtherBCBS
PA03081900OtherCAPITAL BCBS