Provider Demographics
NPI:1245421007
Name:WELLSPRINGS CHIROPRACTIC
Entity Type:Organization
Organization Name:WELLSPRINGS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-519-1881
Mailing Address - Street 1:937 RUSSELL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3280
Mailing Address - Country:US
Mailing Address - Phone:301-519-1881
Mailing Address - Fax:301-519-1131
Practice Address - Street 1:937 RUSSELL AVE STE B
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3280
Practice Address - Country:US
Practice Address - Phone:301-519-1881
Practice Address - Fax:301-519-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01987111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG01483Medicare PIN
MDU98567Medicare UPIN