Provider Demographics
NPI:1518949841
Name:TROUT CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:TROUT CHIROPRACTIC CENTER PC
Other - Org Name:S CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:TROUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-436-9885
Mailing Address - Street 1:22 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIFFLINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17059-1003
Mailing Address - Country:US
Mailing Address - Phone:717-436-9885
Mailing Address - Fax:717-436-5025
Practice Address - Street 1:22 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-1003
Practice Address - Country:US
Practice Address - Phone:717-436-8281
Practice Address - Fax:717-436-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001304L111N00000X
SC795111N00000X
MI2301004216111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PATR994246OtherBLUE SHIELD
PA0016781900001Medicaid
PA03088800OtherBLUE CROSS
X38584Medicare UPIN
025688Medicare ID - Type Unspecified