Provider Demographics
NPI:1801010418
Name:CHESTERTOWN CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:CHESTERTOWN CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FANNING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-810-0530
Mailing Address - Street 1:819B HIGH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-1100
Mailing Address - Country:US
Mailing Address - Phone:410-810-0530
Mailing Address - Fax:410-810-0200
Practice Address - Street 1:819B HIGH ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1100
Practice Address - Country:US
Practice Address - Phone:410-810-0530
Practice Address - Fax:410-810-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01718111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDW4570001OtherBLUECROSS BLUESHIELD
MDS01718OtherLICENSE NUMBER
MDM281OtherBLUECROSS BLUESHIELD
MD366QMedicare ID - Type Unspecified