Provider Demographics
NPI:1619168499
Name:ABUNDANT LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:ABUNDANT LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PAMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-866-1933
Mailing Address - Street 1:9070 PEACH ST
Mailing Address - Street 2:SUITE #1
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-4078
Mailing Address - Country:US
Mailing Address - Phone:814-866-1933
Mailing Address - Fax:814-866-1934
Practice Address - Street 1:9070 PEACH ST
Practice Address - Street 2:SUITE #1
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-4078
Practice Address - Country:US
Practice Address - Phone:814-866-1933
Practice Address - Fax:814-866-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC8650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1014200490001Medicaid
PA074651Medicare PIN