Provider Demographics
NPI:1710279831
Name:UPPER CERVICAL CHIROPRACTIC NEUROLOGY CENTER, P.C.
Entity Type:Organization
Organization Name:UPPER CERVICAL CHIROPRACTIC NEUROLOGY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CONICELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:484-593-0328
Mailing Address - Street 1:533 W UWCHLAN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-1763
Mailing Address - Country:US
Mailing Address - Phone:484-593-0328
Mailing Address - Fax:
Practice Address - Street 1:533 W UWCHLAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-1763
Practice Address - Country:US
Practice Address - Phone:484-593-0328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-08
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009298111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA221336OtherMEDICARE PTAN