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General NPI Number Information
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NPI Number | 1700219656
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Entity Type | Organization
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Legal Business Name | RENEW-REBUILD-REHABILITATE CHIROPRACTIC CENTER, LLC
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Dates
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Enumeration Date | 08/14/2013
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Last Update Date | 08/14/2013
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Provider Practice Location Address
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Address Line | 312 MARTIN LUTHER KING JR BLVD SUITE 100
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City | BALTIMORE
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State | MD
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Zip | 21201-1221
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Country | US
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Telephone | 410-366-3250
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5001
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City | SEVERNA PARK
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State | MD
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Zip | 21146-0360
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Country | US
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Telephone | 410-366-3250
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Fax | 410-366-3252
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Authorized Official
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Title or Position | OWNER
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Name | DR. SUE ELLEN PODMIJERSKY
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Credential | D.C.
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Telephone | 410-366-3250
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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 | S01679
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License Number State | MD
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