1053487702 NPI number — WALDOBORO CHIROPRACTIC CENTER PA

Table of content: (NPI 1053487702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053487702 NPI number — WALDOBORO CHIROPRACTIC CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALDOBORO CHIROPRACTIC CENTER PA
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:
1053487702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 625
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WALDOBORO
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04572-0625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-832-6347
Provider Business Mailing Address Fax Number:
207-832-4664

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
290 BREMEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALDOBORO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04572-0625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-832-6347
Provider Business Practice Location Address Fax Number:
207-832-4664
Provider Enumeration Date:
11/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
207-832-6347

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CR875 , 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: 129130100 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 022301 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".




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