=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215153481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELLERIN CHIROPRACTIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1413 ANNPOLIS ROAD SUITE 100
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-1672
-----------------------------------------------------
Fax | 410-672-1700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1413 ANNPOLIS ROAD SUITE 100
-----------------------------------------------------
City | ODENTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-672-1672
-----------------------------------------------------
Fax | 410-672-1700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. GINGER RENEE PELLERIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 410-672-1672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 03482
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------