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General NPI Number Information
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NPI Number | 1457737967
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Entity Type | Organization
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Legal Business Name | NORTHERN LIBERTIES WELLNESS GROUP
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Dates
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Enumeration Date | 08/06/2015
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Last Update Date | 08/06/2015
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Provider Practice Location Address
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Address Line | 520 N COLUMBUS BLVD 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 | PO BOX 9900
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City | HAMILTON
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State | NJ
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Zip | 08650-1900
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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 | ADMINISTRATOR
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Name | MS. LOLAMARIE DAVIS
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Credential |
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Telephone | 215-239-3096
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | DC002363
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | OS011923
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License Number State | PA
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