Provider Demographics
NPI:1841417730
Name:ADVANTAGE CHIROPRACTIC P A
Entity Type:Organization
Organization Name:ADVANTAGE CHIROPRACTIC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ERICH
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-699-2226
Mailing Address - Street 1:894 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-4350
Mailing Address - Country:US
Mailing Address - Phone:207-699-2226
Mailing Address - Fax:207-699-2229
Practice Address - Street 1:894 BROADWAY
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-4350
Practice Address - Country:US
Practice Address - Phone:207-699-2226
Practice Address - Fax:207-699-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME177050000Medicaid
ME=========OtherTAX ID
ME=========OtherTAX ID