Provider Demographics
NPI:1851456008
Name:VANCE, PHILIP LAMONT (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LAMONT
Last Name:VANCE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:PHILIP
Other - Middle Name:L
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:10 CONEWANGO AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365
Mailing Address - Country:US
Mailing Address - Phone:814-723-2060
Mailing Address - Fax:814-723-6244
Practice Address - Street 1:10 CONEWANGO AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365
Practice Address - Country:US
Practice Address - Phone:814-723-2060
Practice Address - Fax:814-723-6244
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001832L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
126455Medicare ID - Type Unspecified
T29326Medicare UPIN