Provider Demographics
NPI:1881321560
Name:MAIN STREET CHIRO LLC
Entity type:Organization
Organization Name:MAIN STREET CHIRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARAK
Authorized Official - Middle Name:NAVIN
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-904-3061
Mailing Address - Street 1:24 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-1039
Mailing Address - Country:US
Mailing Address - Phone:856-904-3061
Mailing Address - Fax:215-332-8691
Practice Address - Street 1:24 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-1039
Practice Address - Country:US
Practice Address - Phone:856-904-3061
Practice Address - Fax:215-332-8691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1036188000001Medicaid
1083056683OtherPERSONAL NPI