Healthcare Provider Details

I. General information

NPI: 1831257096
Provider Name (Legal Business Name): PREMIER CHIROPRACTIC AND REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 E 25TH ST
BALTIMORE MD
21218-5142
US

IV. Provider business mailing address

22 E 25TH ST
BALTIMORE MD
21218-5142
US

V. Phone/Fax

Practice location:
  • Phone: 410-235-6280
  • Fax: 410-235-6281
Mailing address:
  • Phone: 410-235-6280
  • Fax: 410-235-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberS03399
License Number StateMD

VIII. Authorized Official

Name: DR. MOHAMMAD FARAZDAGHI
Title or Position: PRESIDENT
Credential: D.C
Phone: 410-235-6280