=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124158902
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALLIVAN FAMILY CHIROPRACTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3821 LINGLESTOWN RD
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17110-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-671-9141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3821 LINGLESTOWN RD
-----------------------------------------------------
City | HARRISBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17110-3631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-671-9141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY PATRICK GALLIVAN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 717-671-9141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | AJ-006596-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------