Provider Demographics
NPI:1841233806
Name:FRY, JOHN SAMUEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SAMUEL
Last Name:FRY
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 1177
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-1177
Mailing Address - Country:US
Mailing Address - Phone:304-522-7246
Mailing Address - Fax:304-522-0018
Practice Address - Street 1:4600A ROUTE 152
Practice Address - Street 2:
Practice Address - City:LAVALETTE
Practice Address - State:WV
Practice Address - Zip Code:25535-9702
Practice Address - Country:US
Practice Address - Phone:304-522-7246
Practice Address - Fax:304-522-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1066162OtherWORKERS COMP VENDOR #
WV52244677500OtherWORKERS COMP ID
WV7600032000Medicaid
WVU72436Medicare UPIN
WV52244677500OtherWORKERS COMP ID
WVFR0860784Medicare ID - Type UnspecifiedMEDICARE ID