Provider Demographics
NPI:1306034236
Name:BROWN CHIROPRACTIC
Entity Type:Organization
Organization Name:BROWN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-341-5544
Mailing Address - Street 1:1767 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2132
Mailing Address - Country:US
Mailing Address - Phone:570-341-5544
Mailing Address - Fax:570-341-5545
Practice Address - Street 1:1767 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2132
Practice Address - Country:US
Practice Address - Phone:570-341-5544
Practice Address - Fax:570-341-5545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC0004338-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012212490002Medicaid
PA0012212490002Medicaid