Provider Demographics
NPI:1770834566
Name:CAVALLO CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:CAVALLO CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:I JOHNATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-351-0631
Mailing Address - Street 1:656 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW HOLLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17557-1410
Mailing Address - Country:US
Mailing Address - Phone:717-351-0631
Mailing Address - Fax:717-351-0631
Practice Address - Street 1:656 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW HOLLAND
Practice Address - State:PA
Practice Address - Zip Code:17557-1410
Practice Address - Country:US
Practice Address - Phone:717-351-0631
Practice Address - Fax:717-351-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005766L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU50397Medicare UPIN
PA038580Medicare PIN