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General NPI Number Information
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NPI Number | 1902853070
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Entity Type | Organization
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Legal Business Name | STRUCTURAL DISORDERS OF THE SPINE
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 21 NORTH 4TH STREET
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City | HARRISBURG
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State | PA
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Zip | 17101
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Country | US
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Telephone | 717-233-3476
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Fax | 717-796-2409
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Provider Business Mailing Address
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Address Line | 21 NORTH 4TH STREET
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City | HARRISBURG
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State | PA
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Zip | 17101
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Country | US
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Telephone | 717-233-3476
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Fax | 717-796-2409
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Authorized Official
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Title or Position | OWNER
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Name | DR. JASON MICHAEL FULLMER
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Credential | DC
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Telephone | 717-460-3422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 009494
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License Number State | PA
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