Provider Demographics
NPI:1336175918
Name:WALCOTT CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:WALCOTT CHIROPRACTIC, P.C.
Other - Org Name:ADVANCED WELLNESS CENTER OF PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:VAILL
Authorized Official - Last Name:WALCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-493-1590
Mailing Address - Street 1:1548 REVERE RD
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-4351
Mailing Address - Country:US
Mailing Address - Phone:215-493-1590
Mailing Address - Fax:
Practice Address - Street 1:14260 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-1108
Practice Address - Country:US
Practice Address - Phone:215-676-0104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007908L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2125718000OtherPERSONAL CHOICE GROUP ID
PA2125718000OtherKEYSTONE GROUP ID
PA3063269OtherAETNA HMO
PA7979272OtherAETNA TRADITIONAL
PA0060935000OtherAMERIHEALTH PIN ID
PA056172OtherBLUE SHIELD
PAP00240657OtherRR MEDICARE
PA1437125OtherBLUE SHIELD GROUP ID
PADD6376OtherRR MEDICARE GROUP ID
PA0060935000OtherPERSONAL CHOICE
PA0060935000OtherKEYSTONE
PA2192178OtherUNITED HEALTHCARE
PA0060935000OtherAMERIHEALTH PIN ID
PA056172OtherBLUE SHIELD
PA044045RUSMedicare ID - Type UnspecifiedMEDICARE