Provider Demographics
NPI:1659782217
Name:VITAE CHIROPRACTIC AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:VITAE CHIROPRACTIC AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:TARRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:267-968-4810
Mailing Address - Street 1:911 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-1559
Mailing Address - Country:US
Mailing Address - Phone:610-825-5606
Mailing Address - Fax:610-825-5622
Practice Address - Street 1:911 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-1559
Practice Address - Country:US
Practice Address - Phone:610-825-5606
Practice Address - Fax:610-825-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC0009997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA093021Medicare PIN