Provider Demographics
NPI:1720044480
Name:LANE, SANDRA B (DC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:B
Last Name:LANE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 813
Mailing Address - Street 2:166 WEST TIOGA STREET
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-0813
Mailing Address - Country:US
Mailing Address - Phone:570-836-2751
Mailing Address - Fax:570-836-3290
Practice Address - Street 1:166 W TIOGA ST
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-1466
Practice Address - Country:US
Practice Address - Phone:570-836-2751
Practice Address - Fax:570-836-3290
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-004456-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012324490002Medicaid
PA60656880OtherSTATE INDUSTRIAL ACCIDENT
PA815631OtherPPO NUMBER B3
PA0012324490002Medicaid