Provider Demographics
NPI:1811050966
Name:STATE LINE CHIROPRACTIC CENTER, PA
Entity type:Organization
Organization Name:STATE LINE CHIROPRACTIC CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HOLTFRERICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-291-0156
Mailing Address - Street 1:8170 W 135TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-1112
Mailing Address - Country:US
Mailing Address - Phone:913-291-0156
Mailing Address - Fax:
Practice Address - Street 1:8170 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-1112
Practice Address - Country:US
Practice Address - Phone:913-291-0156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0104388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS25203014OtherBCBS PROVIDER NUMBER
KSU71873Medicare UPIN
KS25203014OtherBCBS PROVIDER NUMBER