Healthcare Provider Details

I. General information

NPI: 1093748485
Provider Name (Legal Business Name): GRANITE RUN CHIROPRACTIC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93A W MAIN ST
LEOLA PA
17540-1803
US

IV. Provider business mailing address

93A W MAIN ST
LEOLA PA
17540-1803
US

V. Phone/Fax

Practice location:
  • Phone: 717-656-5422
  • Fax: 717-656-5403
Mailing address:
  • Phone: 717-656-5422
  • Fax: 717-656-5403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL L FULLER
Title or Position: OWNER
Credential: DC
Phone: 717-656-5422