=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700258787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE CHIROPRACTIC AND REHABILITATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2015
-----------------------------------------------------
Last Update Date | 11/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 UNIVERSITY BLVD W STE 210
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20901-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-863-3710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 344 UNIVERSITY BLVD W STE 210
-----------------------------------------------------
City | SILVER SPRING
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20901-1970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-863-3710
-----------------------------------------------------
Fax | 301-844-5724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. THERESA T ANKRAH
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 240-863-3710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | S03770
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------