Provider Demographics
NPI:1578747960
Name:TROLLEY SQUARE PAIN RELIEF CTR
Entity Type:Organization
Organization Name:TROLLEY SQUARE PAIN RELIEF CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-421-3660
Mailing Address - Street 1:1523 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-3005
Mailing Address - Country:US
Mailing Address - Phone:302-421-3660
Mailing Address - Fax:302-421-3662
Practice Address - Street 1:1523 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-3005
Practice Address - Country:US
Practice Address - Phone:302-421-3660
Practice Address - Fax:302-421-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1629135942OtherINDIVIDUAL NPI