1194935874 NPI number — CHIROPRACTIC PAIN & REHABILITATION CENTER

Table of content: (NPI 1194935874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194935874 NPI number — CHIROPRACTIC PAIN & REHABILITATION CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROPRACTIC PAIN & REHABILITATION CENTER
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:
1194935874
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:
226 VENICE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEPHERDSTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25443-4648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-876-0500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1185 MOUNT AETNA RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
HAGERSTOWN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21740-6832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-739-0790
Provider Business Practice Location Address Fax Number:
301-739-0353
Provider Enumeration Date:
05/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
U
Authorized Official Title or Position:
SOLE PROPRITOR
Authorized Official Telephone Number:
301-739-0790

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  S01325 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1017515 . This is a "BRICKSTREET" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 609578 . This is a "ACN GROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: M080 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 220619 . This is a "MAMSI OPTIMUM CHOICE ONE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7946642 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 345287 . This is a "COVENTRY HEALTH" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: R155 . This is a "FEB" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 095990 . This is a "US HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 41578 . This is a "IWIF" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 212092 . This is a "KAISER PERMANENTE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: EJ1004587 . This is a "ASHN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: R155001 . This is a "CAREFIRST BLUECHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 4277955 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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