Provider Demographics
NPI:1235294745
Name:ITKIN CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ITKIN CHIROPRACTIC PC
Other - Org Name:NORTHEAST REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:ITKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-676-3236
Mailing Address - Street 1:14425 BUSTLETON AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116
Mailing Address - Country:US
Mailing Address - Phone:215-676-3236
Mailing Address - Fax:215-676-4275
Practice Address - Street 1:14425 BUSTLETON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116
Practice Address - Country:US
Practice Address - Phone:215-676-3236
Practice Address - Fax:215-676-4275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2017-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01530727Medicaid
IT779560Medicare ID - Type Unspecified
U58554Medicare UPIN