Provider Demographics
NPI:1063469740
Name:CHIROPRACTIC SPINE CENTER IV
Entity Type:Organization
Organization Name:CHIROPRACTIC SPINE CENTER IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAZER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-254-8200
Mailing Address - Street 1:744 W LANCASTER AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2523
Mailing Address - Country:US
Mailing Address - Phone:610-254-8200
Mailing Address - Fax:610-254-8263
Practice Address - Street 1:744 W LANCASTER AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2523
Practice Address - Country:US
Practice Address - Phone:610-254-8200
Practice Address - Fax:610-254-8263
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007347L111NR0400X
PAAJ-007347-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty