Provider Demographics
NPI:1366638371
Name:ESSEX CHIROPRACTIC
Entity Type:Organization
Organization Name:ESSEX CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC,DPT
Authorized Official - Phone:978-686-7111
Mailing Address - Street 1:493 ESSEX ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01840-1241
Mailing Address - Country:US
Mailing Address - Phone:978-686-7111
Mailing Address - Fax:978-686-5502
Practice Address - Street 1:493 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1241
Practice Address - Country:US
Practice Address - Phone:978-686-7111
Practice Address - Fax:978-686-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2154111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39894OtherBCBS