Provider Demographics
NPI:1154393981
Name:FANELLA, RICHARD TIMOTHY SR (DC)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:TIMOTHY
Last Name:FANELLA
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 WARREN ROAD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701
Mailing Address - Country:US
Mailing Address - Phone:724-464-0400
Mailing Address - Fax:724-464-0800
Practice Address - Street 1:2340 WARREN ROAD
Practice Address - Street 2:SUITE 203
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701
Practice Address - Country:US
Practice Address - Phone:724-464-0400
Practice Address - Fax:724-464-0800
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007597L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
746872Medicare UPIN
PA031908Medicare ID - Type Unspecified