Provider Demographics
NPI:1225033004
Name:LAVORGNA, BLAISE MITCHELL (DC)
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:MITCHELL
Last Name:LAVORGNA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 1859
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21802-1859
Mailing Address - Country:US
Mailing Address - Phone:410-341-6520
Mailing Address - Fax:410-341-6526
Practice Address - Street 1:32071 BEAVES RUN DRIVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-341-6520
Practice Address - Fax:410-341-6526
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1405PT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM466Medicare ID - Type Unspecified
MDT59575Medicare UPIN