Provider Demographics
NPI:1912112418
Name:AMBROSE S PERDUK JR DC INC
Entity Type:Organization
Organization Name:AMBROSE S PERDUK JR DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBROSE
Authorized Official - Middle Name:S
Authorized Official - Last Name:PERDUK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:330-343-2621
Mailing Address - Street 1:125 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2931
Mailing Address - Country:US
Mailing Address - Phone:330-343-2621
Mailing Address - Fax:330-343-6006
Practice Address - Street 1:125 W 2ND STREET
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2931
Practice Address - Country:US
Practice Address - Phone:330-343-2621
Practice Address - Fax:330-343-6006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1155111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0707668Medicaid
OHT48326Medicare UPIN
OH0707668Medicaid