Provider Demographics
NPI:1861732463
Name:RED LION CHIROPRACTIC CENTER, PC
Entity type:Organization
Organization Name:RED LION CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-464-0404
Mailing Address - Street 1:842 RED LION RD
Mailing Address - Street 2:#8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1475
Mailing Address - Country:US
Mailing Address - Phone:215-464-0404
Mailing Address - Fax:215-464-0683
Practice Address - Street 1:842 RED LION RD
Practice Address - Street 2:#8
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-1475
Practice Address - Country:US
Practice Address - Phone:215-464-0404
Practice Address - Fax:215-464-0683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006295L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015288270001Medicaid
PA0015288270001Medicaid