Provider Demographics
NPI:1831166883
Name:PRIMAVERA, DENISE LUELLA (DC)
Entity type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:LUELLA
Last Name:PRIMAVERA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:DENISE
Other - Middle Name:LUELLA
Other - Last Name:GRUBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 QUINCE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969
Mailing Address - Country:US
Mailing Address - Phone:215-721-6356
Mailing Address - Fax:
Practice Address - Street 1:4019 BETHLEHEM PIKE
Practice Address - Street 2:
Practice Address - City:TELFORD
Practice Address - State:PA
Practice Address - Zip Code:18969-1126
Practice Address - Country:US
Practice Address - Phone:215-723-7900
Practice Address - Fax:215-723-4481
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005445L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2627638OtherAETNA GROUP
PA2729465OtherAETNA
U43349Medicare UPIN
PAPR774667Medicare ID - Type Unspecified