Healthcare Provider Details

I. General information

NPI: 1538941117
Provider Name (Legal Business Name): WISTERIA PAIN AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W CHELTENHAM AVE STE 312
WYNCOTE PA
19095-2946
US

IV. Provider business mailing address

2401 W CHELTENHAM AVE STE 312
WYNCOTE PA
19095-2946
US

V. Phone/Fax

Practice location:
  • Phone: 445-300-7313
  • Fax: 445-269-5619
Mailing address:
  • Phone: 215-722-9074
  • Fax: 445-269-5619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. CHRISTIAN ACHARTE
Title or Position: PRESIDENT
Credential: MD
Phone: 215-722-9074