Provider Demographics
NPI:1417328295
Name:PATCH CHIROPRACTIC PA
Entity Type:Organization
Organization Name:PATCH CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-677-4000
Mailing Address - Street 1:605 GLEN AVE
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1125
Mailing Address - Country:US
Mailing Address - Phone:856-335-5060
Mailing Address - Fax:856-793-9392
Practice Address - Street 1:701 E GATE DR
Practice Address - Street 2:SUITE 304
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-3838
Practice Address - Country:US
Practice Address - Phone:856-677-4000
Practice Address - Fax:856-234-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00726900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty