1003257031 NPI number — VITASOURCE CHIROPRACTIC & REHABILITATION LLC

Table of content: MS. DONNA MAE BRISTOW FNP (NPI 1982828968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003257031 NPI number — VITASOURCE CHIROPRACTIC & REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITASOURCE CHIROPRACTIC & REHABILITATION LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003257031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1831 W CHELTENHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKINS PARK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19027-1049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-276-2250
Provider Business Mailing Address Fax Number:
215-276-2110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1831 W CHELTENHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKINS PARK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19027-1049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-276-2250
Provider Business Practice Location Address Fax Number:
215-276-2110
Provider Enumeration Date:
07/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FONTAINE
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
HAROLD
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC
Authorized Official Telephone Number:
215-276-2250

Provider Taxonomy Codes

  • Taxonomy code: 111NX0100X , with the licence number:  DC010306 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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