Provider Demographics
NPI:1043376684
Name:PROVIDENCE CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:PROVIDENCE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:LANCELLOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:401-354-5120
Mailing Address - Street 1:1637 MINERAL SPRING AVENUE SUITE 201
Mailing Address - Street 2:
Mailing Address - City:NORTH PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-354-5120
Mailing Address - Fax:401-354-5122
Practice Address - Street 1:1637 MINERAL SPRING AVENUE SUITE 201
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-354-5120
Practice Address - Fax:401-354-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
720028401OtherCIGNA
RI0000003521OtherBC BS RI
RI400742OtherBLUE CHIP
4400421OtherUNITED
RI0000003521OtherBC BS RI
720028401OtherCIGNA