Provider Demographics
NPI:1912005539
Name:PERSICHETTI, LOUIS EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:EDWARD
Last Name:PERSICHETTI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CENTRE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4131
Mailing Address - Country:US
Mailing Address - Phone:856-596-8484
Mailing Address - Fax:856-596-7146
Practice Address - Street 1:106 CENTRE BLVD STE B
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4131
Practice Address - Country:US
Practice Address - Phone:856-596-8484
Practice Address - Fax:856-596-7146
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00269100111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6284906Medicaid
NJU32845Medicare UPIN
NJ631839Medicare ID - Type Unspecified