1700219656 NPI number — RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700219656 NPI number — RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, 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:
1700219656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEVERNA PARK
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21146-0360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-366-3250
Provider Business Mailing Address Fax Number:
410-366-3252

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21201-1221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-366-3250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PODMIJERSKY
Authorized Official First Name:
SUE ELLEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-366-3250

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  S01679 , 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)





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