Provider Demographics
NPI:1437202900
Name:DORCHESTER CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:DORCHESTER CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-436-5454
Mailing Address - Street 1:1504 DORCHESTER AVE # B
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1327
Mailing Address - Country:US
Mailing Address - Phone:617-436-5454
Mailing Address - Fax:617-436-5667
Practice Address - Street 1:1504 DORCHESTER AVE # B
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1327
Practice Address - Country:US
Practice Address - Phone:617-436-5454
Practice Address - Fax:617-436-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1561111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1613383Medicaid
MA1613383Medicaid