Provider Demographics
NPI:1306866843
Name:INNATE CHIROPRACTIC, PC
Entity Type:Organization
Organization Name:INNATE CHIROPRACTIC, PC
Other - Org Name:CREATING WELLNESS AT INNATE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIZETTE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ECKERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-775-7468
Mailing Address - Street 1:210 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2424
Mailing Address - Country:US
Mailing Address - Phone:207-775-7468
Mailing Address - Fax:207-775-1080
Practice Address - Street 1:210 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2424
Practice Address - Country:US
Practice Address - Phone:207-775-7468
Practice Address - Fax:207-775-1080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1111111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEIN-ME1794Medicare ID - Type Unspecified