Healthcare Provider Details

I. General information

NPI: 1629251830
Provider Name (Legal Business Name): MARYLAND SPINE REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 MERRITT BLVD
DUNDALK MD
21222-2113
US

IV. Provider business mailing address

PO BOX 745854
ATLANTA GA
30374-5854
US

V. Phone/Fax

Practice location:
  • Phone: 410-285-0920
  • Fax:
Mailing address:
  • Phone: 410-970-8190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. LOUIS S CRIVELLI II
Title or Position: OWNER
Credential: D.C., M.S., C.N.S.
Phone: 301-652-7717