Provider Demographics
NPI:1700086139
Name:CHIROPRACTIC WELLNESS CENTER OF BALTIMORE, LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC WELLNESS CENTER OF BALTIMORE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-529-8010
Mailing Address - Street 1:8723 BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-2419
Mailing Address - Country:US
Mailing Address - Phone:410-529-8010
Mailing Address - Fax:410-529-8424
Practice Address - Street 1:8723 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-2419
Practice Address - Country:US
Practice Address - Phone:410-529-8010
Practice Address - Fax:410-529-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02080111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD61706801OtherBLUE CROSS
MDKCZ8CHOtherBLUE CROSS PROVIDER
MD400455800Medicaid
G911OtherBLUE CROSS PROVIDER
MD61706801OtherBLUE CROSS
G911OtherBLUE CROSS PROVIDER