Healthcare Provider Details

I. General information

NPI: 1851369078
Provider Name (Legal Business Name): JASON MICHAEL DEPIETROPAOLO D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 S MAIN ST
OLD FORGE PA
18518-1542
US

IV. Provider business mailing address

19 CAREY LN
PITTSTON PA
18640-3225
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-0977
  • Fax: 570-457-1279
Mailing address:
  • Phone: 570-655-8887
  • Fax: 570-457-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC-007551-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: