Provider Demographics
NPI:1124093042
Name:EDINBORO FAMILY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:EDINBORO FAMILY CHIROPRACTIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:AMY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-734-4541
Mailing Address - Street 1:12650 EDINBORO RD
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-2263
Mailing Address - Country:US
Mailing Address - Phone:814-734-4541
Mailing Address - Fax:814-734-5562
Practice Address - Street 1:12650 EDINBORO RD
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-2263
Practice Address - Country:US
Practice Address - Phone:814-734-4541
Practice Address - Fax:814-734-5562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007922L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU84298Medicare UPIN
PA046464Medicare ID - Type Unspecified