MEDICARE: DIVINE CHIROPRACTIC AND REHABILITATION LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	S03770	MD

General Provider Information

NPI Number	:	1700258787
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE CHIROPRACTIC AND REHABILITATION LLC

Provider Business Mailing Address
First Line	:	344 UNIVERSITY BLVD W STE 210
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20901-1970
Country	:	US
Telephone Number	:	240-863-3710
Fax Number	:	301-844-5724

Provider Business Practice Location Address
First Line	:	344 UNIVERSITY BLVD W STE 210
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20901-1970
Country	:	US
Telephone Number	:	240-863-3710
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. THERESA T ANKRAH
Credential	:	D.C
Telephone Number	:	240-863-3710

Provider Enumeration Date	:	10/29/2015
Last Update Date	:	11/05/2015

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