1659542918 NPI number — HERITAGE FAMILY CHIROPRACTIC

Table of content: (NPI 1659542918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659542918 NPI number — HERITAGE FAMILY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERITAGE FAMILY 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:
HERITAGE INTEGRATIVE HEALTHCARE
Provider Other Organization Name Type Code:
3
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:
1659542918
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
80 LEIGHTON RD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
FALMOUTH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04105-2242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-321-2100
Provider Business Mailing Address Fax Number:
207-321-2101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 LEIGHTON ROAD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
FALMOUTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04105-2242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-321-2100
Provider Business Practice Location Address Fax Number:
207-321-2101
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-321-2100

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CR1312 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 043860 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: AA28305 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: M216561 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 3949217 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 190080000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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