Provider Demographics
NPI:1578505418
Name:TELLER, JARRAD RYAN (DC)
Entity type:Individual
Prefix:
First Name:JARRAD
Middle Name:RYAN
Last Name:TELLER
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 1:7016 TERMINAL SQ
Mailing Address - Street 2:SUITE 10A
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2310
Mailing Address - Country:US
Mailing Address - Phone:610-352-1710
Mailing Address - Fax:610-352-1740
Practice Address - Street 1:7016 TERMINAL SQ
Practice Address - Street 2:SUITE 10A
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2310
Practice Address - Country:US
Practice Address - Phone:610-352-1710
Practice Address - Fax:610-352-1740
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007527L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU75173Medicare UPIN
PA027181Medicare ID - Type Unspecified