Provider Demographics
NPI:1255575940
Name:IRON HAVEN GYM & CHIROPRACTIC
Entity type:Organization
Organization Name:IRON HAVEN GYM & CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:NICASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-243-6396
Mailing Address - Street 1:290 E POMFRET ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-2579
Mailing Address - Country:US
Mailing Address - Phone:717-243-6396
Mailing Address - Fax:717-243-6444
Practice Address - Street 1:290 E POMFRET ST
Practice Address - Street 2:SUITE #3
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17013-2579
Practice Address - Country:US
Practice Address - Phone:717-243-6396
Practice Address - Fax:717-243-6444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA004892L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU46465Medicare UPIN