Provider Demographics
NPI:1154752392
Name:MAIN STREET CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:MAIN STREET CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRILYN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-882-5742
Mailing Address - Street 1:382 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-5046
Mailing Address - Country:US
Mailing Address - Phone:603-882-5742
Mailing Address - Fax:
Practice Address - Street 1:382 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5046
Practice Address - Country:US
Practice Address - Phone:603-882-5742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-12
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1120493111N00000X
111N00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH0023867OtherMEDICARE
NH615742OtherOPTUM
NH2612118OtherUNITED
NH3557492OtherCIGNA
NHAA228827OtherHARVARD
NH12289121OtherCAQH
NH5554684OtherAETNA