Provider Demographics
NPI:1053526681
Name:ADVANCED CHIROPRACTIC OF ALTOONA
Entity type:Organization
Organization Name:ADVANCED CHIROPRACTIC OF ALTOONA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-941-5353
Mailing Address - Street 1:332 W PLANK ROAD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-941-5353
Mailing Address - Fax:814-283-0066
Practice Address - Street 1:332 W PLANK ROAD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602
Practice Address - Country:US
Practice Address - Phone:814-941-5353
Practice Address - Fax:814-283-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009558111N00000X
PADC006800L111N00000X
PADC006430L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA016360920002Medicaid
PA016360920002Medicaid