=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750475554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIO ALBERT GRIPPA D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 11/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 373 VIRGINIA AVE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15074-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-775-1002
-----------------------------------------------------
Fax | 724-775-2527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 373 VIRGINIA AVE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15074-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-775-1002
-----------------------------------------------------
Fax | 724-775-2527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC004847L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------