Healthcare Provider Details

I. General information

NPI: 1629128772
Provider Name (Legal Business Name): PORTAGE CHIROPRACTIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 CALDWELL AVE SUITE 102
PORTAGE PA
15946-1571
US

IV. Provider business mailing address

808 CALDWELL AVE SUITE 102
PORTAGE PA
15946-1571
US

V. Phone/Fax

Practice location:
  • Phone: 814-736-9897
  • Fax:
Mailing address:
  • Phone: 814-736-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC006906R
License Number StatePA

VIII. Authorized Official

Name: DR. JAMES M. HERALD
Title or Position: OWNER
Credential: D.C.
Phone: 814-736-9897