Healthcare Provider Details

I. General information

NPI: 1619300530
Provider Name (Legal Business Name): DE JESUS WELLNESS GROUP, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 ROCK GLEN RD
SUGARLOAF PA
18249-3211
US

IV. Provider business mailing address

298 ROCK GLEN RD
SUGARLOAF PA
18249-3211
US

V. Phone/Fax

Practice location:
  • Phone: 570-708-2228
  • Fax: 570-708-2039
Mailing address:
  • Phone: 570-708-2228
  • Fax: 570-708-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC004270L
License Number StatePA

VIII. Authorized Official

Name: DR. ROWENA M. DE JESUS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 570-708-2228