1376692764 NPI number — BACK TO NORMAL CHIROPRACTIC, PC

Table of content: (NPI 1376692764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376692764 NPI number — BACK TO NORMAL CHIROPRACTIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BACK TO NORMAL CHIROPRACTIC, PC
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:
1376692764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 253
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IPSWICH
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01938-0253
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-317-6756
Provider Business Mailing Address Fax Number:
978-412-9099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 CENTRAL ST
Provider Second Line Business Practice Location Address:
UNIT 3
Provider Business Practice Location Address City Name:
IPSWICH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01938-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-317-6756
Provider Business Practice Location Address Fax Number:
978-412-9099
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PADUCHAK
Authorized Official First Name:
SWIATOSLAW
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
978-317-6756

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH1689 , 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: 1376692764 . This is a "NPPES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: Y39686 . This is a "BCBSMA" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1851379721 . This is a "NPPES" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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