1124243340 NPI number — LIFELINE FAMILY CHIROPRACTIC

Table of content: (NPI 1124243340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124243340 NPI number — LIFELINE FAMILY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE FAMILY CHIROPRACTIC
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:
1124243340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 711
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19446-0901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-368-4222
Provider Business Mailing Address Fax Number:
215-368-8321

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
628 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19446-2964
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-368-4222
Provider Business Practice Location Address Fax Number:
215-368-8321
Provider Enumeration Date:
04/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WASSERMANN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
215-368-4222

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  DC-005166-L , 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)

  • Identifier: 1891792701 . This is a "BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1891792701 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2409794000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2409794000 . This is a "HIGHMARK" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2306381 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2409794000 . This is a "PERSONAL CHOICE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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