Provider Demographics
NPI:1316936602
Name:WISE CHIROPRACTIC & REHABILITATION CENTER INC
Entity type:Organization
Organization Name:WISE CHIROPRACTIC & REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PT
Authorized Official - Prefix:
Authorized Official - First Name:VON
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-748-7462
Mailing Address - Street 1:5 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1243
Mailing Address - Country:US
Mailing Address - Phone:570-748-7462
Mailing Address - Fax:570-748-8910
Practice Address - Street 1:5 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1243
Practice Address - Country:US
Practice Address - Phone:570-748-7462
Practice Address - Fax:570-748-8910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0076902450003Medicaid
PA1322904OtherBLUE SHIELD
PA1322904OtherBLUE SHIELD