Provider Demographics
NPI:1922250760
Name:DURELL L. DECARLO DC, PC
Entity Type:Organization
Organization Name:DURELL L. DECARLO DC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-437-8200
Mailing Address - Street 1:150 WAYLAND SMITH DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-2677
Mailing Address - Country:US
Mailing Address - Phone:724-437-8200
Mailing Address - Fax:724-437-6673
Practice Address - Street 1:150 WAYLAND SMITH DR
Practice Address - Street 2:SUITE A
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-2677
Practice Address - Country:US
Practice Address - Phone:724-437-8200
Practice Address - Fax:724-437-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007461111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019128830002Medicaid
PA0019128830002Medicaid