Provider Demographics
NPI:1215157714
Name:MCCORMICK DEPASQUE CHIROPRACTIC, PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MCCORMICK DEPASQUE CHIROPRACTIC, PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-657-3200
Mailing Address - Street 1:1031 N. YORK ROAD
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090
Mailing Address - Country:US
Mailing Address - Phone:215-657-3200
Mailing Address - Fax:215-657-6875
Practice Address - Street 1:1031 YORK RD
Practice Address - Street 2:
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090-1317
Practice Address - Country:US
Practice Address - Phone:215-657-3200
Practice Address - Fax:215-657-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004523L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA642772Medicare ID - Type Unspecified