Provider Demographics
NPI:1700955697
Name:BLAISE LAVORGNA DC
Entity Type:Organization
Organization Name:BLAISE LAVORGNA DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAISE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:LAVORGNA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-341-6520
Mailing Address - Street 1:32071 BEAVER RUN DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804
Mailing Address - Country:US
Mailing Address - Phone:410-341-6520
Mailing Address - Fax:410-341-6526
Practice Address - Street 1:32071 BEAVER RUN DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804
Practice Address - Country:US
Practice Address - Phone:410-341-6520
Practice Address - Fax:410-341-6526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1405PT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDM466Medicare PIN