Provider Demographics
NPI:1194935874
Name:CHIROPRACTIC PAIN & REHABILITATION CENTER
Entity type:Organization
Organization Name:CHIROPRACTIC PAIN & REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRITOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:U
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-739-0790
Mailing Address - Street 1:226 VENICE WAY
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-4648
Mailing Address - Country:US
Mailing Address - Phone:304-876-0500
Mailing Address - Fax:
Practice Address - Street 1:1185 MOUNT AETNA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6832
Practice Address - Country:US
Practice Address - Phone:301-739-0790
Practice Address - Fax:301-739-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01325111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1017515OtherBRICKSTREET
MD609578OtherACN GROUP
MDM080OtherCAREFIRST
MD220619OtherMAMSI OPTIMUM CHOICE ONE
MD7946642OtherCIGNA HEALTHCARE
MD345287OtherCOVENTRY HEALTH
MDR155OtherFEB
MD095990OtherUS HEALTHCARE
MD41578OtherIWIF
MD212092OtherKAISER PERMANENTE
MDEJ1004587OtherASHN
MDR155001OtherCAREFIRST BLUECHOICE
MD4277955OtherAETNA
MD41578OtherIWIF
MD095990OtherUS HEALTHCARE
MD220619OtherMAMSI OPTIMUM CHOICE ONE