1588759039 NPI number — GREATER LOWELL CHIROPRACTIC REHABILITATION INC

Table of content: (NPI 1588759039)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588759039 NPI number — GREATER LOWELL CHIROPRACTIC REHABILITATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER LOWELL CHIROPRACTIC REHABILITATION INC
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:
1588759039
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
249 CENTRAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01852-2214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-452-1466
Provider Business Mailing Address Fax Number:
978-452-1826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
249 CENTRAL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01852-2214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-452-1466
Provider Business Practice Location Address Fax Number:
978-452-1826
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRODERICK
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
978-452-1466

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  230 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PR1697 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 468952 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 63563 . This is a "FALLON" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y36807 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 351369 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 606350 . This is a "CIGNA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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