=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235513516
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY J TRIPP D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2615 W GIRARD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-519-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 873 N JUDSON ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19130-1936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-519-2811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC011035
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------