Provider Demographics
NPI:1407071525
Name:OLD TOWNE CHIROPRACTIC SERVICES LTD
Entity Type:Organization
Organization Name:OLD TOWNE CHIROPRACTIC SERVICES LTD
Other - Org Name:OLD TOWNE CHIROPRACTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:K
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEYOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-684-0260
Mailing Address - Street 1:1218 KING ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2927
Mailing Address - Country:US
Mailing Address - Phone:703-684-0260
Mailing Address - Fax:703-684-0262
Practice Address - Street 1:1218 KING ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2927
Practice Address - Country:US
Practice Address - Phone:703-684-0260
Practice Address - Fax:703-684-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA014000399111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA237347OtherBCBS OR ANTHEM BCBS OF VA
VA237347OtherBCBS OR ANTHEM BCBS OF VA
T73423Medicare UPIN