Provider Demographics
NPI:1356660997
Name:KEYSTONE PAIN MANAGEMENT
Entity Type:Organization
Organization Name:KEYSTONE PAIN MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-351-1710
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:CEDAR BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08018-0154
Mailing Address - Country:US
Mailing Address - Phone:609-704-1857
Mailing Address - Fax:609-704-1859
Practice Address - Street 1:7016 TERMINAL SQ
Practice Address - Street 2:SUITE 10A
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2337
Practice Address - Country:US
Practice Address - Phone:610-352-1710
Practice Address - Fax:610-352-1740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007527L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty