1154752392 NPI number — MAIN STREET CHIROPRACTIC, LLC

Table of content: (NPI 1154752392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154752392 NPI number — MAIN STREET CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAIN STREET CHIROPRACTIC, LLC
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:
1154752392
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
382 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHUA
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03060-5046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-882-5742
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
382 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NASHUA
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03060-5046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-882-5742
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
JERRILYN
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
603-882-5742

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1120493 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0023867 . This is a "MEDICARE" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 615742 . This is a "OPTUM" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 2612118 . This is a "UNITED" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 3557492 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: AA228827 . This is a "HARVARD" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 12289121 . This is a "CAQH" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 5554684 . This is a "AETNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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