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General NPI Number Information
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NPI Number | 1144318825
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Entity Type | Organization
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Legal Business Name | MAIN STREET CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 10/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5760 MAIN ST
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City | ELKRIDGE
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State | MD
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Zip | 21075-5019
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Country | US
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Telephone | 410-579-1777
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Fax | 410-579-1778
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Provider Business Mailing Address
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Address Line | 1819 FAIRVIEW AVE
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City | HALETHORPE
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State | MD
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Zip | 21227-4509
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | RESIDENT AGENT
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Name | JANINE DINAN
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Credential | D.C.
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Telephone | 443-851-1914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 03465
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License Number State | MD
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