Provider Demographics
NPI:1952346538
Name:DIAMOND STATE CHIROPRACTIC PA
Entity type:Organization
Organization Name:DIAMOND STATE CHIROPRACTIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MADRON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-892-9355
Mailing Address - Street 1:1101 TWIN C LN STE 201
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2159
Mailing Address - Country:US
Mailing Address - Phone:302-892-9355
Mailing Address - Fax:302-892-3494
Practice Address - Street 1:1101 TWIN C LN STE 201
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2159
Practice Address - Country:US
Practice Address - Phone:302-892-9355
Practice Address - Fax:302-892-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
DEF100000198111N00000X
DEF100000597111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG00273Medicare ID - Type UnspecifiedMEDICARE GROUP ID