Provider Demographics
NPI:1003152182
Name:NOVA CHIROPRACTIC GROUP
Entity Type:Organization
Organization Name:NOVA CHIROPRACTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:LAOL
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-772-1031
Mailing Address - Street 1:118 MAINE MALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2309
Mailing Address - Country:US
Mailing Address - Phone:207-772-1031
Mailing Address - Fax:207-774-9394
Practice Address - Street 1:118 MAINE MALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2309
Practice Address - Country:US
Practice Address - Phone:207-772-1031
Practice Address - Fax:207-774-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR2103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1205975042OtherALL OTHER INSURANCE COMPANIES