Provider Demographics
NPI:1568504413
Name:SOUTHAMPTON CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:SOUTHAMPTON CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:FIORDALISO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-942-7990
Mailing Address - Street 1:PO BOX 321
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-0321
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
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:2007-02-13
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006513L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA869972Medicare ID - Type Unspecified