Provider Demographics
NPI:1790968956
Name:BLACKLEDGE, PAUL DONALD (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DONALD
Last Name:BLACKLEDGE
Suffix:
Gender:M
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 271
Mailing Address - Street 2:
Mailing Address - City:PECKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18452-0271
Mailing Address - Country:US
Mailing Address - Phone:570-383-4963
Mailing Address - Fax:570-383-4964
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447-1241
Practice Address - Country:US
Practice Address - Phone:570-383-4963
Practice Address - Fax:570-383-4964
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor