Provider Demographics
NPI:1194902148
Name:PENN SPINE & PERFORMANCE CENTER LLC
Entity type:Organization
Organization Name:PENN SPINE & PERFORMANCE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRZEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOGOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:610-524-6680
Mailing Address - Street 1:403 W LINCOLN HWY
Mailing Address - Street 2:SUITE 108
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2559
Mailing Address - Country:US
Mailing Address - Phone:610-524-6680
Mailing Address - Fax:610-524-6681
Practice Address - Street 1:403 W LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2559
Practice Address - Country:US
Practice Address - Phone:610-524-6680
Practice Address - Fax:610-524-6681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADC009869OtherCHIROPRACTIC LICENSE