Healthcare Provider Details

I. General information

NPI: 1649485343
Provider Name (Legal Business Name): SOUTH JERSEY HEALTH & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 GREENTREE RD SUITE A
CHERRY HILL NJ
08003-1115
US

IV. Provider business mailing address

1919 GREENTREE RD
CHERRY HILL NJ
08003-1115
US

V. Phone/Fax

Practice location:
  • Phone: 856-761-8100
  • Fax: 856-761-8107
Mailing address:
  • Phone: 856-761-8100
  • Fax: 856-761-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number38MC00534300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberDC-007149-L
License Number StatePA

VIII. Authorized Official

Name: DR. MICHAEL EDENZON
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 856-761-8100