Healthcare Provider Details

I. General information

NPI: 1316246135
Provider Name (Legal Business Name): POLAND CHIROPRACTIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 N MAIN ST
POLAND OH
44514-1627
US

IV. Provider business mailing address

44 N MAIN ST
POLAND OH
44514-1627
US

V. Phone/Fax

Practice location:
  • Phone: 330-757-4029
  • Fax: 330-757-9192
Mailing address:
  • Phone: 330-757-4029
  • Fax: 330-757-9192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1354
License Number StateOH

VIII. Authorized Official

Name: DR. THOMAS A DIVITO
Title or Position: OWNER
Credential: D,C.
Phone: 330-757-4029