MEDICARE: ALTOONA CHIROPRACTIC LIFE CENTER INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC009194	PA
2	111N00000X	Chiropractor	DC001390-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316017247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTOONA CHIROPRACTIC LIFE CENTER INC.

Provider Business Mailing Address
First Line	:	1405 EAST WALTON AVENUE
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602
Country	:	US
Telephone Number	:	814-946-0279
Fax Number	:	814-946-9039

Provider Business Practice Location Address
First Line	:	1405 EAST WALTON AVENUE
Second Line	:
City	:	ALTOONA
State	:	PA
Zip	:	16602
Country	:	US
Telephone Number	:	814-946-0279
Fax Number	:	814-946-9039

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HARRY JOSEPH FYE JR.
Credential	:	D.C.
Telephone Number	:	814-946-0279

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	08/22/2020

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