Provider Demographics
NPI:1407004013
Name:SOUTHAMPTON CHIROPRACTIC & WELLNESS CENTER, PC
Entity Type:Organization
Organization Name:SOUTHAMPTON CHIROPRACTIC & WELLNESS CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:FIORDALISO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-942-7990
Mailing Address - Street 1:454 SECOND STREET PIKE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3814
Mailing Address - Country:US
Mailing Address - Phone:215-942-7990
Mailing Address - Fax:
Practice Address - Street 1:454 SECOND STREET PIKE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3814
Practice Address - Country:US
Practice Address - Phone:215-942-7990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006513L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0872754000OtherINDEPENDENCE BLUE CROSS
P913224OtherOXFORD
PA919212OtherHIGHMARK
PA0857457OtherAETNA
PA0857457OtherAETNA