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General NPI Number Information
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NPI Number | 1346668530
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Entity Type | Organization
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Legal Business Name | NORTHERN LIBETIES WELLNESS CENTER
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Dates
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Enumeration Date | 04/03/2014
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Last Update Date | 04/03/2014
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Provider Practice Location Address
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Address Line | 520 N DELAWARE AVE SUITE 202
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City | PHILADELPHIA
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State | PA
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Zip | 19123-4226
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Country | US
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Telephone | 215-239-3097
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Fax | 215-239-3098
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Provider Business Mailing Address
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Address Line | 520 N DELAWARE AVE SUITE 202
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City | PHILADELPHIA
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State | PA
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Zip | 19123-4226
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Country | US
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Telephone | 215-239-3097
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Fax | 215-239-3098
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Authorized Official
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Title or Position | OWNER
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Name | DR. WAYNE GIBBONS
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Credential | MD
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Telephone | 21523930697
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | MD 038770L
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License Number State | PA
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