Provider Demographics
NPI:1700219656
Name:RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUE ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PODMIJERSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-366-3250
Mailing Address - Street 1:PO BOX 5001
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-0360
Mailing Address - Country:US
Mailing Address - Phone:410-366-3250
Mailing Address - Fax:410-366-3252
Practice Address - Street 1:312 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1221
Practice Address - Country:US
Practice Address - Phone:410-366-3250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01679111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty