=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952105702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIC DEVON KADZIELA D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 04/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 246 S LEHIGH AVE
-----------------------------------------------------
City | FRACKVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17931-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-874-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 N NICE ST
-----------------------------------------------------
City | FRACKVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17931-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-391-6844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC012032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------