MEDICARE: CONCORDIA CENTER OF CLINICAL CHIROPRACTIC &REHABILITATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	DC010142	PA

General Provider Information

NPI Number	:	1588995328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCORDIA CENTER OF CLINICAL CHIROPRACTIC &REHABILITATION LLC

Provider Business Mailing Address
First Line	:	346 BASSWOOD CIR
Second Line	:
City	:	FEASTERVILLE TREVOSE
State	:	PA
Zip	:	19053-7217
Country	:	US
Telephone Number	:	215-280-8229
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 BUSTLETON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19152-1918
Country	:	US
Telephone Number	:	215-280-8229
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ITZHAK KAGANOVICH
Credential	:	D.C.
Telephone Number	:	215-280-8229

Provider Enumeration Date	:	01/19/2010
Last Update Date	:	01/19/2010

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