Provider Demographics
NPI:1518074368
Name:J ERIC LEFEVRE, DC, PC
Entity Type:Organization
Organization Name:J ERIC LEFEVRE, DC, PC
Other - Org Name:PARK STREET CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LEFEVRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-784-0360
Mailing Address - Street 1:519 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-2328
Mailing Address - Country:US
Mailing Address - Phone:570-784-0360
Mailing Address - Fax:570-784-0804
Practice Address - Street 1:519 PARK ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-2328
Practice Address - Country:US
Practice Address - Phone:570-784-0360
Practice Address - Fax:570-784-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005505-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU49631Medicare UPIN