MEDICARE: SUPER CHIROPRACTIC LIFE CENTER LLP

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

General Provider Information

NPI Number	:	1750973673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPER CHIROPRACTIC LIFE CENTER LLP

Provider Business Mailing Address
First Line	:	2 LEES LN
Second Line	:
City	:	HADDON TOWNSHIP
State	:	NJ
Zip	:	08107-1091
Country	:	US
Telephone Number	:	856-858-5511
Fax Number	:	856-858-2317

Provider Business Practice Location Address
First Line	:	2 LEES LN
Second Line	:
City	:	HADDON TOWNSHIP
State	:	NJ
Zip	:	08107-1091
Country	:	US
Telephone Number	:	856-858-5511
Fax Number	:	856-858-2317

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	GWENDOLYN SUPER
Credential	:
Telephone Number	:	856-858-5511

Provider Enumeration Date	:	02/11/2021
Last Update Date	:	02/18/2021

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