Healthcare Provider Details

I. General information

NPI: 1740405604
Provider Name (Legal Business Name): NORTH EAST CHIROPRACTIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 PULASKI HWY STE B
NORTH EAST MD
21901-3730
US

IV. Provider business mailing address

2316 PULASKI HWY STE B
NORTH EAST MD
21901-3730
US

V. Phone/Fax

Practice location:
  • Phone: 410-642-9110
  • Fax: 410-642-9113
Mailing address:
  • Phone: 410-642-9110
  • Fax: 410-642-9113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number02079
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02079
License Number StateMD

VIII. Authorized Official

Name: DR. HEATHER MCCOY BLACKISTON
Title or Position: OWNER
Credential: D.C.
Phone: 410-642-9110