Healthcare Provider Details

I. General information

NPI: 1518206457
Provider Name (Legal Business Name): DECARLO ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2013
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 SECOND STREET PIKE BLDG. B
RICHBORO PA
18954-1067
US

IV. Provider business mailing address

123 SWALLOW RD
HOLLAND PA
18966-1953
US

V. Phone/Fax

Practice location:
  • Phone: 215-364-1331
  • Fax: 215-322-7551
Mailing address:
  • Phone: 215-364-1331
  • Fax: 215-322-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC-003441-L
License Number StatePA

VIII. Authorized Official

Name: DR. JOSEPH THOMAS DE CARLO
Title or Position: PRESIDENT
Credential: D.C.
Phone: 215-364-1331