Provider Demographics
NPI:1609061654
Name:ATHLETIC EDGE CHIROPRACTIC & REHABILITATION LLC
Entity type:Organization
Organization Name:ATHLETIC EDGE CHIROPRACTIC & REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-940-6756
Mailing Address - Street 1:1982 BUTLER PIKE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-3701
Mailing Address - Country:US
Mailing Address - Phone:610-940-6756
Mailing Address - Fax:610-940-6797
Practice Address - Street 1:1982 BUTLER PIKE
Practice Address - Street 2:SUITE #2
Practice Address - City:CONSHOHOCKEN
Practice Address - State:PA
Practice Address - Zip Code:19428-3701
Practice Address - Country:US
Practice Address - Phone:610-940-6756
Practice Address - Fax:610-940-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11585W2YMedicare PIN