1184713737 NPI number — MALLETTS BAY CHIROPRACTIC

Table of content: (NPI 1184713737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184713737 NPI number — MALLETTS BAY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALLETTS BAY CHIROPRACTIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184713737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 768
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLCHESTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05446-0768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-865-2255
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 HEINEBERG DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLCHESTER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05446-6772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-865-2255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIEBMAN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
802-865-2255

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  808 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4427 . This is a "VT BLUE CROSS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com