Provider Demographics
NPI:1538173380
Name:ALTAVILLA, LAURA J (DC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:ALTAVILLA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:123 WHITNEY STREET
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440
Mailing Address - Country:US
Mailing Address - Phone:978-632-5885
Mailing Address - Fax:978-630-3774
Practice Address - Street 1:123 WHITNEY STREET
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440
Practice Address - Country:US
Practice Address - Phone:978-632-5885
Practice Address - Fax:978-630-3774
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1336111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
2045784OtherFIRST HEALTH CNN HCVM
MA1609149Medicaid
1609149OtherMASSHEALTH
351050OtherHARVARD PILGRIM
043116527OtherTAX ID
15021OtherFALLON
898687OtherFOCUS BEECH STREET
986271OtherNETWORK HEALTH
Y35953OtherMEDICARE
203139600OtherACS DEPT OF LABOR
30700OtherCIGNA
OO13407OtherNEIGHBORHOOD
350053673OtherRR MEDICARE PALMETTO
80705OtherONE HEALTH GREAT WEST
RRCAT810191834OtherPRIVATE HEALTHCARE SYSTEM
Y35953OtherBCBS
210035OtherACN ASHN
4481980OtherAETNA