=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346592250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILDEBRAND CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2012
-----------------------------------------------------
Last Update Date | 10/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1460 MARTIN ST
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16803-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-238-8540
-----------------------------------------------------
Fax | 814-238-8638
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1460 MARTIN ST
-----------------------------------------------------
City | STATE COLLEGE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16803-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-238-8540
-----------------------------------------------------
Fax | 814-238-8638
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. RUSSELL JOSEPH HILDEBRAND
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 814-238-8540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------