Provider Demographics
NPI:1912204488
Name:QUAD-STATE CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:QUAD-STATE CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-733-1635
Mailing Address - Street 1:1209B DIVISION HWY
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522-8822
Mailing Address - Country:US
Mailing Address - Phone:717-733-1635
Mailing Address - Fax:
Practice Address - Street 1:1209B DIVISION HWY
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-8822
Practice Address - Country:US
Practice Address - Phone:717-733-1635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-18
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007174L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty