Provider Demographics
NPI:1346518602
Name:MCCLELLAN CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:MCCLELLAN CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:850-674-2555
Mailing Address - Street 1:17390 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1763
Mailing Address - Country:US
Mailing Address - Phone:850-674-2555
Mailing Address - Fax:850-674-2576
Practice Address - Street 1:17390 MAIN ST N
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1763
Practice Address - Country:US
Practice Address - Phone:850-674-2555
Practice Address - Fax:850-674-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6803111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3805913 00Medicaid
FL55165Medicare PIN
FLU51169Medicare UPIN