=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275825804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST CHIROPRACTIC CENTER PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2011
-----------------------------------------------------
Last Update Date | 07/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 HANCOCK ST SUITE 2G
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-6573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-990-5711
-----------------------------------------------------
Fax | 207-990-5712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 HANCOCK ST 2G
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-6573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-990-5711
-----------------------------------------------------
Fax | 207-990-5712
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR/CEO
-----------------------------------------------------
Name | DR. GEORGE P DE MAERTELAERE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 207-990-5711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number | CR739
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------