Provider Demographics
NPI:1629251830
Name:MARYLAND SPINE REHAB, LLC
Entity Type:Organization
Organization Name:MARYLAND SPINE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:CRIVELLI
Authorized Official - Suffix:II
Authorized Official - Credentials:DC, MS, CNS
Authorized Official - Phone:301-652-7717
Mailing Address - Street 1:PO BOX 745854
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-5854
Mailing Address - Country:US
Mailing Address - Phone:410-970-8190
Mailing Address - Fax:
Practice Address - Street 1:1515 MERRITT BLVD
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2113
Practice Address - Country:US
Practice Address - Phone:410-285-0920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG02097Medicare PIN