Provider Demographics
NPI:1760548598
Name:FANELLA CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:FANELLA CHIROPRACTIC CLINIC PC
Other - Org Name:FANELLA CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:FANELLA
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:724-464-0400
Mailing Address - Street 1:2340 WARREN ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-464-0400
Mailing Address - Fax:724-464-0800
Practice Address - Street 1:2340 WARREN ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-464-0400
Practice Address - Fax:724-464-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007597L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA031908Medicare ID - Type Unspecified
746872Medicare UPIN