Provider Demographics
NPI:1568557254
Name:GORMAN CHIROPRACTIC LIFE CENTERS PC
Entity Type:Organization
Organization Name:GORMAN CHIROPRACTIC LIFE CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:R
Authorized Official - Last Name:GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-476-4100
Mailing Address - Street 1:21CRYSTAL STREET
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301
Mailing Address - Country:US
Mailing Address - Phone:570-476-4100
Mailing Address - Fax:570-476-7669
Practice Address - Street 1:21 CRYSTAL STREET
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301
Practice Address - Country:US
Practice Address - Phone:570-476-4100
Practice Address - Fax:570-476-7669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002838L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7710165OtherAETNA
PA813927OtherFIRST PRIORITY
PA114185Medicare PIN
PA813927OtherFIRST PRIORITY