Provider Demographics
NPI:1356480404
Name:MILLENNIUM CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:MILLENNIUM CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:FERN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-934-5401
Mailing Address - Street 1:1619 GRANT AVE
Mailing Address - Street 2:GRANT PLAZA II
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19115
Mailing Address - Country:US
Mailing Address - Phone:215-934-5401
Mailing Address - Fax:215-934-5452
Practice Address - Street 1:1619 GRANT AVE
Practice Address - Street 2:GRANT PLAZA II
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19115
Practice Address - Country:US
Practice Address - Phone:215-934-5401
Practice Address - Fax:215-934-5452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC006309L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2053318000OtherIBC
PAMI1361038OtherBLUE SHIELD
058551Medicare ID - Type Unspecified
PAMI1361038OtherBLUE SHIELD