Provider Demographics
NPI:1003847260
Name:MT JACKSON CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:MT JACKSON CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOSAFLOOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-667-7160
Mailing Address - Street 1:500 MT JACKSON ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16102-2618
Mailing Address - Country:US
Mailing Address - Phone:724-667-7160
Mailing Address - Fax:724-667-8807
Practice Address - Street 1:500 MT JACKSON ROAD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16102-2618
Practice Address - Country:US
Practice Address - Phone:724-667-7160
Practice Address - Fax:724-667-8807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004657L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA418693OtherHIGHMARK GROUP NUMBER
PAY18693OtherBLUE SHIELD
PA035733NXUMedicare UPIN