Provider Demographics
NPI:1679600100
Name:ULTIMO, CALEB (DC)
Entity Type:Individual
Prefix:MR
First Name:CALEB
Middle Name:
Last Name:ULTIMO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2951
Mailing Address - Country:US
Mailing Address - Phone:508-586-1173
Mailing Address - Fax:
Practice Address - Street 1:263 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5325
Practice Address - Country:US
Practice Address - Phone:508-588-7100
Practice Address - Fax:508-588-7101
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3095111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA7753977OtherAETNA
MAY37176OtherBLUE CROSS BLUE SHIELD
MAV12579Medicare UPIN
MA00000561Medicare PIN