Provider Demographics
NPI:1821189564
Name:SPECTRUM WELLNESS LLC
Entity Type:Organization
Organization Name:SPECTRUM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-938-8500
Mailing Address - Street 1:2321 HUNTINGDON PIKE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-6109
Mailing Address - Country:US
Mailing Address - Phone:215-938-8500
Mailing Address - Fax:251-938-8586
Practice Address - Street 1:2321 HUNTINGDON PIKE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-6109
Practice Address - Country:US
Practice Address - Phone:215-938-8500
Practice Address - Fax:251-938-8586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005180L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1818597OtherHIGHMARK BLUE SHIELD
2674216000OtherINDEPENDENCE BLUE CROSS
0043800OtherCIGNA
106962Medicare PIN