Provider Demographics
NPI:1710231915
Name:NEW IMAGE & WELLNESS
Entity Type:Organization
Organization Name:NEW IMAGE & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-513-8439
Mailing Address - Street 1:1924 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLMES
Mailing Address - State:PA
Mailing Address - Zip Code:19043-1442
Mailing Address - Country:US
Mailing Address - Phone:610-513-8439
Mailing Address - Fax:
Practice Address - Street 1:2401 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 1 A2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3010
Practice Address - Country:US
Practice Address - Phone:215-792-3197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-09
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002444L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty