Provider Demographics
NPI:1487989786
Name:HERITAGE CHIROPRACTIC INC
Entity type:Organization
Organization Name:HERITAGE CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:T
Authorized Official - Last Name:PAVKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:814-796-0077
Mailing Address - Street 1:18 N PARK ROW
Mailing Address - Street 2:PO BOX 77
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441-8308
Mailing Address - Country:US
Mailing Address - Phone:814-796-0077
Mailing Address - Fax:814-796-1717
Practice Address - Street 1:18 N PARK ROW
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441-8308
Practice Address - Country:US
Practice Address - Phone:814-796-0077
Practice Address - Fax:814-796-1717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019619510001Medicaid
0000107944Medicare PIN