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General NPI Number Information
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NPI Number | 1861829632
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Entity Type | Organization
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Legal Business Name | SPORT AND SPINE CHIROPRACTIC REHAB
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Dates
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Enumeration Date | 10/10/2013
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Last Update Date | 10/10/2013
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Provider Practice Location Address
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Address Line | 8 N GROVE ST SUITE B
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City | LOCK HAVEN
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State | PA
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Zip | 17745-3547
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Country | US
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Telephone | 570-858-5645
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Fax | 570-858-5687
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Provider Business Mailing Address
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Address Line | 8 N GROVE ST SUITE B
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City | LOCK HAVEN
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State | PA
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Zip | 17745-3547
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Country | US
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Telephone | 570-858-5645
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Fax | 570-858-5687
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JASON MADIGAN
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Credential | D.C.
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Telephone | 570-858-5645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | DC009059
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License Number State | PA
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