Provider Demographics
NPI:1316017247
Name:ALTOONA CHIROPRACTIC LIFE CENTER INC.
Entity Type:Organization
Organization Name:ALTOONA CHIROPRACTIC LIFE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FYE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:814-946-0279
Mailing Address - Street 1:1405 EAST WALTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-946-0279
Mailing Address - Fax:814-946-9039
Practice Address - Street 1:1405 EAST WALTON AVENUE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602
Practice Address - Country:US
Practice Address - Phone:814-946-0279
Practice Address - Fax:814-946-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001390-L111N00000X
PADC009194111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006347810001Medicaid
PA1009207200001Medicaid
PA0006347810001Medicaid
PA077101Medicare ID - Type UnspecifiedBRETT A FYE
PAU98967Medicare UPIN
PA1009207200001Medicaid