Healthcare Provider Details

I. General information

NPI: 1952346538
Provider Name (Legal Business Name): DIAMOND STATE CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 TWIN C LN STE 201
NEWARK DE
19713-2159
US

IV. Provider business mailing address

1101 TWIN C LN STE 201
NEWARK DE
19713-2159
US

V. Phone/Fax

Practice location:
  • Phone: 302-892-9355
  • Fax: 302-892-3494
Mailing address:
  • Phone: 302-892-9355
  • Fax: 302-892-3494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: TODD H BOGOS
Title or Position: OWNER
Credential: DC
Phone: 302-777-5551