Basic Information
| Provider Information | |||||||||
| NPI: | 1447280623 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVANS CHIROPRACTIC CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 182 MAIN ST | ||||||||
| Address2: | PO BOX 484 | ||||||||
| City: | NEW MILFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188342114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704653444 | ||||||||
| FaxNumber: | 5704655400 | ||||||||
| Practice Location | |||||||||
| Address1: | 182 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW MILFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188342114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704653444 | ||||||||
| FaxNumber: | 5704655400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5704653444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC04995L | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 0012964820002 | 05 | PA | MEDICAID | 511796 | 01 | PA | BLUE SHIELD | OTHER | 836180 | 01 | PA | AETNA | OTHER |