Provider Demographics
NPI:1326219734
Name:COORDINATED HEALTH CENTER P C
Entity Type:Organization
Organization Name:COORDINATED HEALTH CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:TICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-667-8412
Mailing Address - Street 1:104 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-2215
Mailing Address - Country:US
Mailing Address - Phone:610-667-8412
Mailing Address - Fax:610-667-8413
Practice Address - Street 1:104 FORREST AVE
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-2215
Practice Address - Country:US
Practice Address - Phone:610-667-8412
Practice Address - Fax:610-667-8413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006360L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA145478000OtherHIGHMARK BS
PA145478000OtherHIGHMARK BS