Provider Demographics
NPI:1124243340
Name:LIFELINE FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:LIFELINE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WASSERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-368-4222
Mailing Address - Street 1:PO BOX 711
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-0901
Mailing Address - Country:US
Mailing Address - Phone:215-368-4222
Mailing Address - Fax:215-368-8321
Practice Address - Street 1:628 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2964
Practice Address - Country:US
Practice Address - Phone:215-368-4222
Practice Address - Fax:215-368-8321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-005166-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1891792701OtherBLUE CROSS
PA1891792701OtherBLUE SHIELD
PA2409794000OtherKEYSTONE
PA2409794000OtherHIGHMARK
PA2306381OtherAETNA
PA2409794000OtherPERSONAL CHOICE
PA2306381OtherAETNA