Provider Demographics
NPI:1740405604
Name:NORTH EAST CHIROPRACTIC PA
Entity Type:Organization
Organization Name:NORTH EAST CHIROPRACTIC PA
Other - Org Name:BLACKISTON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MCCOY
Authorized Official - Last Name:BLACKISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-642-9110
Mailing Address - Street 1:2316 PULASKI HWY STE B
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3730
Mailing Address - Country:US
Mailing Address - Phone:410-642-9110
Mailing Address - Fax:410-642-9113
Practice Address - Street 1:2316 PULASKI HWY STE B
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3730
Practice Address - Country:US
Practice Address - Phone:410-642-9110
Practice Address - Fax:410-642-9113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02079111N00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61670301OtherBC RENDERING PROV. ID
MD2912304OtherAETNA PROV. ID
MD2912304OtherAETNA PROV. ID
MDU90460Medicare UPIN