Provider Demographics
NPI:1861829632
Name:SPORT AND SPINE CHIROPRACTIC REHAB
Entity Type:Organization
Organization Name:SPORT AND SPINE CHIROPRACTIC REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MADIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-858-5645
Mailing Address - Street 1:8 N GROVE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-3547
Mailing Address - Country:US
Mailing Address - Phone:570-858-5645
Mailing Address - Fax:570-858-5687
Practice Address - Street 1:8 N GROVE ST
Practice Address - Street 2:SUITE B
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-3547
Practice Address - Country:US
Practice Address - Phone:570-858-5645
Practice Address - Fax:570-858-5687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009059111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty