Provider Demographics
NPI:1063797694
Name:ELLICOTT CITY WELLNESS CHIROPRACTIC, L.L.C.
Entity type:Organization
Organization Name:ELLICOTT CITY WELLNESS CHIROPRACTIC, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-750-2540
Mailing Address - Street 1:9025 CHEVROLET DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4017
Mailing Address - Country:US
Mailing Address - Phone:410-750-2540
Mailing Address - Fax:410-750-2541
Practice Address - Street 1:9025 CHEVROLET DR
Practice Address - Street 2:SUITE D
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4017
Practice Address - Country:US
Practice Address - Phone:410-750-2540
Practice Address - Fax:410-750-2541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1467 PT111N00000X
MD1468 PT111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDY921-0001OtherCAREFIRST(BRIAN)
MDY921-0002OtherCAREFIRST(LINDSEY)
MDY921OtherCAREFIRST(GROUP#)