Provider Demographics
NPI:1457737967
Name:NORTHERN LIBERTIES WELLNESS GROUP
Entity Type:Organization
Organization Name:NORTHERN LIBERTIES WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LOLAMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-239-3096
Mailing Address - Street 1:PO BOX 9900
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08650-1900
Mailing Address - Country:US
Mailing Address - Phone:215-239-3097
Mailing Address - Fax:215-239-3098
Practice Address - Street 1:520 N COLUMBUS BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-4226
Practice Address - Country:US
Practice Address - Phone:215-239-3097
Practice Address - Fax:215-239-3098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002363111NR0400X
PAOS011923208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty