Provider Demographics
NPI:1417466384
Name:RADIANCE CHIROPRACTIC
Entity Type:Organization
Organization Name:RADIANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRETZ PISCIOTTANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-942-4444
Mailing Address - Street 1:370 SOUTHPOINTE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-8572
Mailing Address - Country:US
Mailing Address - Phone:724-942-4444
Mailing Address - Fax:724-338-4483
Practice Address - Street 1:370 SOUTHPOINTE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-8572
Practice Address - Country:US
Practice Address - Phone:724-942-4444
Practice Address - Fax:724-338-4483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-23
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4148L111N00000X
111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty