MEDICARE: DR. TABETHA SUPER DC

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	DC011420	PA

General Provider Information

NPI Number	:	1972071942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TABETHA SUPER DC

Provider Business Mailing Address
First Line	:	1440 BIRCH ST
Second Line	:
City	:	READING
State	:	PA
Zip	:	19604-1840
Country	:	US
Telephone Number	:	563-514-5444
Fax Number	:

Provider Business Practice Location Address
First Line	:	1440 BIRCH ST
Second Line	:
City	:	READING
State	:	PA
Zip	:	19604-1840
Country	:	US
Telephone Number	:	563-514-5444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2018
Last Update Date	:	11/08/2018

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Directions to “ DR. TABETHA SUPER DC” Practice Location

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