Healthcare Provider Details

I. General information

NPI: 1013160456
Provider Name (Legal Business Name): CHARLES D. CRUICKSHANK, D.C., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2008
Last Update Date: 10/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8615 RIDGELYS CHOICE DR 104
BALTIMORE MD
21236-3026
US

IV. Provider business mailing address

8615 RIDGELYS CHOICE DR 104
BALTIMORE MD
21236-3026
US

V. Phone/Fax

Practice location:
  • Phone: 410-529-3913
  • Fax: 410-529-3916
Mailing address:
  • Phone: 410-529-3913
  • Fax: 410-529-3916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberS01776
License Number StateMD

VIII. Authorized Official

Name: CHARLES DAVID CRUICKSHANK
Title or Position: OWNER/PRESIDENT
Credential: D.C.
Phone: 410-529-3913