Provider Demographics
NPI:1568618361
Name:JEREMY WILKINS CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:JEREMY WILKINS CHIROPRACTIC CLINIC LLC
Other - Org Name:WILKINS CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-542-4252
Mailing Address - Street 1:605 NORTH CHURCH ST.
Mailing Address - Street 2:
Mailing Address - City:MT. PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-1000
Mailing Address - Country:US
Mailing Address - Phone:724-542-4252
Mailing Address - Fax:724-542-4254
Practice Address - Street 1:605 NORTH CHURCH ST.
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-1000
Practice Address - Country:US
Practice Address - Phone:724-542-4252
Practice Address - Fax:724-542-4254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
PADC009166261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030121420001Medicaid