Provider Demographics
NPI:1083059836
Name:MIDDLETOWN CHIROPRACTIC AND REHABILITATION, INC.
Entity Type:Organization
Organization Name:MIDDLETOWN CHIROPRACTIC AND REHABILITATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-376-5830
Mailing Address - Street 1:401 E MAIN ST
Mailing Address - Street 2:SUITE 4-B
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1491
Mailing Address - Country:US
Mailing Address - Phone:302-376-5830
Mailing Address - Fax:302-376-6517
Practice Address - Street 1:401 E MAIN ST
Practice Address - Street 2:SUITE 4-B
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1491
Practice Address - Country:US
Practice Address - Phone:302-376-5830
Practice Address - Fax:302-376-6517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000721111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE136226ZBHZMedicare UPIN