Provider Demographics
NPI:1205995115
Name:BAYSHORE CHIROPRACTIC CENTER PA
Entity type:Organization
Organization Name:BAYSHORE CHIROPRACTIC CENTER PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIETRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:732-264-8900
Mailing Address - Street 1:250 MAPLE PLACE
Mailing Address - Street 2:
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1144
Mailing Address - Country:US
Mailing Address - Phone:732-264-8900
Mailing Address - Fax:732-264-0156
Practice Address - Street 1:250 MAPLE PLACE
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1144
Practice Address - Country:US
Practice Address - Phone:732-264-8900
Practice Address - Fax:732-264-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty