Provider Demographics
NPI:1265630289
Name:DICESARO SPINE & SPORT LLC
Entity Type:Organization
Organization Name:DICESARO SPINE & SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:DICESARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:412-299-3824
Mailing Address - Street 1:PO BOX 861
Mailing Address - Street 2:
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-0861
Mailing Address - Country:US
Mailing Address - Phone:412-299-3824
Mailing Address - Fax:412-299-3828
Practice Address - Street 1:5990 UNIVERSITY BLVD STE 19
Practice Address - Street 2:
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-4229
Practice Address - Country:US
Practice Address - Phone:412-299-3824
Practice Address - Fax:412-299-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty