Provider Demographics
NPI:1801011895
Name:HOWARD COUNTY CHIROPRACTIC SPINE & SPORTS REHABILITATION. LLC
Entity Type:Organization
Organization Name:HOWARD COUNTY CHIROPRACTIC SPINE & SPORTS REHABILITATION. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:ANTICO
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:443-259-0235
Mailing Address - Street 1:8894 STANFORD BLVD
Mailing Address - Street 2:SUITE I02
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-4794
Mailing Address - Country:US
Mailing Address - Phone:443-259-0235
Mailing Address - Fax:443-259-0236
Practice Address - Street 1:8894 STANFORD BLVD
Practice Address - Street 2:SUITE I02
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-4794
Practice Address - Country:US
Practice Address - Phone:443-259-0235
Practice Address - Fax:443-259-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01939111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty