=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376635805
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BE TRANSFORMED CHIROPRACTIC, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 01/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2609 JENKINTOWN RD
-----------------------------------------------------
City | GLENSIDE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19038-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-659-7345
-----------------------------------------------------
Fax | 215-780-1221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2609 JENKINTOWN RD
-----------------------------------------------------
City | GLENSIDE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19038-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-659-7345
-----------------------------------------------------
Fax | 215-780-1221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK E BARNARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-659-7345
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC-004904-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------