Provider Demographics
NPI:1891104196
Name:REYNOLDSVILLE CHIROPRACTIC LIFE CENTER, LLC
Entity Type:Organization
Organization Name:REYNOLDSVILLE CHIROPRACTIC LIFE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-653-9514
Mailing Address - Street 1:105 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15851-1244
Mailing Address - Country:US
Mailing Address - Phone:814-653-9514
Mailing Address - Fax:814-653-8842
Practice Address - Street 1:105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15851-1244
Practice Address - Country:US
Practice Address - Phone:814-653-9514
Practice Address - Fax:814-653-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC001679L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891104196OtherNPI