Provider Demographics
NPI:1770545402
Name:PINE VALLEY CHIROPRACTIC CLINIC, INC.
Entity type:Organization
Organization Name:PINE VALLEY CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-733-2225
Mailing Address - Street 1:783 PINE VALLLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15239
Mailing Address - Country:US
Mailing Address - Phone:724-733-2225
Mailing Address - Fax:724-733-2500
Practice Address - Street 1:783 PINE VALLLEY DRIVE
Practice Address - Street 2:
Practice Address - City:PLUM
Practice Address - State:PA
Practice Address - Zip Code:15239
Practice Address - Country:US
Practice Address - Phone:724-733-2225
Practice Address - Fax:724-733-2500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007105L111N00000X
PADC007205L111N00000X
PADC006907L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA362849OtherBC/BS
PA058113Medicare ID - Type Unspecified