Healthcare Provider Details

I. General information

NPI: 1063469740
Provider Name (Legal Business Name): CHIROPRACTIC SPINE CENTER IV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W LANCASTER AVE SUITE 105
WAYNE PA
19087-2523
US

IV. Provider business mailing address

744 W LANCASTER AVE SUITE 105
WAYNE PA
19087-2523
US

V. Phone/Fax

Practice location:
  • Phone: 610-254-8200
  • Fax: 610-254-8263
Mailing address:
  • Phone: 610-254-8200
  • Fax: 610-254-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC007347L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberAJ-007347-L
License Number StatePA

VIII. Authorized Official

Name: DR. THEODORE GLAZER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 610-254-8200