Healthcare Provider Details

I. General information

NPI: 1033541495
Provider Name (Legal Business Name): TOTAL HEALTH & REHAB CHIROPRACTIC-PHYSICAL THERAPY-WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8894 STANFORD BLVD SUITE 102
COLUMBIA MD
21045-4794
US

IV. Provider business mailing address

8894 STANFORD BLVD SUITE 102
COLUMBIA MD
21045-4794
US

V. Phone/Fax

Practice location:
  • Phone: 443-259-0235
  • Fax:
Mailing address:
  • Phone: 443-259-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberS01939
License Number StateMD

VIII. Authorized Official

Name: DR. RUSSELL ANTICO
Title or Position: OWNER
Credential: D.C.
Phone: 443-259-0235