Basic Information
| Provider Information | |||||||||
| NPI: | 1992019236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES COLE MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CCMH CHIROPRACTIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | COUDERSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 169158161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142749301 | ||||||||
| FaxNumber: | 8142740807 | ||||||||
| Practice Location | |||||||||
| Address1: | 45 N PINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ALLEGANY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167431238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146425076 | ||||||||
| FaxNumber: | 8146425942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 07/28/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITCHFORD | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 8142749300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHARLES COLE MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.