Provider Demographics
NPI:1699913483
Name:MISTRETTA CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:MISTRETTA CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-588-3939
Mailing Address - Street 1:5 GREENVILLE ORTHOPEDIC CENTER
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16125
Mailing Address - Country:US
Mailing Address - Phone:724-588-3939
Mailing Address - Fax:724-588-6313
Practice Address - Street 1:5 GREENVILLE ORTHOPEDIC CENTER
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16125-0407
Practice Address - Country:US
Practice Address - Phone:724-588-3939
Practice Address - Fax:724-588-6313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003842L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA056940Medicaid