Provider Demographics
NPI:1649485343
Name:SOUTH JERSEY HEALTH & WELLNESS CENTER
Entity type:Organization
Organization Name:SOUTH JERSEY HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EDENZON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-761-8100
Mailing Address - Street 1:1919 GREENTREE RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08003-1115
Mailing Address - Country:US
Mailing Address - Phone:856-761-8100
Mailing Address - Fax:856-761-8107
Practice Address - Street 1:1919 GREENTREE RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-1115
Practice Address - Country:US
Practice Address - Phone:856-761-8100
Practice Address - Fax:856-761-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00534300111NN1001X
PADC-007149-L111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty