=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699913483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISTRETTA CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2009
-----------------------------------------------------
Last Update Date | 02/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 GREENVILLE ORTHOPEDIC CENTER
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125-0407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-3939
-----------------------------------------------------
Fax | 724-588-6313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 GREENVILLE ORTHOPEDIC CENTER
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-588-3939
-----------------------------------------------------
Fax | 724-588-6313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN PAUL MISTRETTA
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 724-588-3939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC003842L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------