Provider Demographics
NPI:1689719502
Name:WALTHAM CHIROPRACTIC PC
Entity Type:Organization
Organization Name:WALTHAM CHIROPRACTIC PC
Other - Org Name:DR JOHN DUFFY
Other - Org Type:Other Name
Authorized Official - Title/Position:DR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CASSIDY
Authorized Official - Last Name:DUFFY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:781-894-4270
Mailing Address - Street 1:425 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453
Mailing Address - Country:US
Mailing Address - Phone:781-894-4270
Mailing Address - Fax:781-894-0461
Practice Address - Street 1:425 RIVER ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-894-4270
Practice Address - Fax:781-894-0461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1644111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA79917Medicaid
MAY36152Medicare ID - Type Unspecified