=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134979784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIC POTTSVILLE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2024
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 E ARCH ST STE 102
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-2982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-622-0809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 442
-----------------------------------------------------
City | POTTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17901-0442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GENE LEVINSTEIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 610-776-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------