Provider Demographics
NPI:1679865547
Name:KING OF PRUSSIA CHIROPRACTIC&HOLISTIC WELLNESS CENTER LLC
Entity type:Organization
Organization Name:KING OF PRUSSIA CHIROPRACTIC&HOLISTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDI
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-265-2522
Mailing Address - Street 1:860 FIRST AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-4033
Mailing Address - Country:US
Mailing Address - Phone:610-265-2522
Mailing Address - Fax:
Practice Address - Street 1:860 FIRST AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-4033
Practice Address - Country:US
Practice Address - Phone:610-265-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003324L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty