Healthcare Provider Details

I. General information

NPI: 1346668530
Provider Name (Legal Business Name): NORTHERN LIBETIES WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2014
Last Update Date: 04/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N DELAWARE AVE SUITE 202
PHILADELPHIA PA
19123-4226
US

IV. Provider business mailing address

520 N DELAWARE AVE SUITE 202
PHILADELPHIA PA
19123-4226
US

V. Phone/Fax

Practice location:
  • Phone: 215-239-3097
  • Fax: 215-239-3098
Mailing address:
  • Phone: 215-239-3097
  • Fax: 215-239-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberMD 038770L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. WAYNE GIBBONS
Title or Position: OWNER
Credential: MD
Phone: 21523930697