Provider Demographics
NPI:1275825804
Name:NORTHEAST CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:NORTHEAST CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DE MAERTELAERE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-990-5711
Mailing Address - Street 1:304 HANCOCK ST
Mailing Address - Street 2:2G
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6573
Mailing Address - Country:US
Mailing Address - Phone:207-990-5711
Mailing Address - Fax:207-990-5712
Practice Address - Street 1:304 HANCOCK ST
Practice Address - Street 2:SUITE 2G
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6573
Practice Address - Country:US
Practice Address - Phone:207-990-5711
Practice Address - Fax:207-990-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR739111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME122650099Medicaid
MET79485Medicare UPIN
MEMM2344Medicare PIN