Provider Demographics
NPI:1821236340
Name:ADVNATAGE CHIROPRACTIC AND REHABILITATION
Entity Type:Organization
Organization Name:ADVNATAGE CHIROPRACTIC AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HEVERIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-579-7374
Mailing Address - Street 1:PO BOX 22342
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19110-2342
Mailing Address - Country:US
Mailing Address - Phone:215-333-6160
Mailing Address - Fax:215-333-6140
Practice Address - Street 1:8400 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2012
Practice Address - Country:US
Practice Address - Phone:215-333-6160
Practice Address - Fax:215-333-6140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA088418Medicare PIN