Provider Demographics
NPI:1548349442
Name:LAVALETTE CHIROPRACTIC INC
Entity type:Organization
Organization Name:LAVALETTE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:FRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-522-7246
Mailing Address - Street 1:PO BOX 1177
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-1177
Mailing Address - Country:US
Mailing Address - Phone:304-522-7246
Mailing Address - Fax:304-522-0018
Practice Address - Street 1:4600A ROUTE 152
Practice Address - Street 2:
Practice Address - City:LAVALETTE
Practice Address - State:WV
Practice Address - Zip Code:25535
Practice Address - Country:US
Practice Address - Phone:304-522-7246
Practice Address - Fax:304-522-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1066162OtherWV WORKERS COMP VENDOR
WVP00195054OtherMEDICARE RAILROAD CARRIER
WV7600032000Medicaid
WV001720189OtherBLUE CROSS BLUE SHIELD ID
WV1841233806OtherNPI FOR JOHN FRY, DC
WV001720189OtherBLUE CROSS BLUE SHIELD ID
OH=========-00OtherOHIO WORKERS' COMP.
WV=========OtherTAX ID
OH=========-00OtherOHIO WORKERS' COMP.