Provider Demographics
NPI:1386707776
Name:FAIRWAY CHIROPRACTIC CLINIC, PC
Entity type:Organization
Organization Name:FAIRWAY CHIROPRACTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:978-851-9055
Mailing Address - Street 1:1501 MAIN ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876-4725
Mailing Address - Country:US
Mailing Address - Phone:978-851-9055
Mailing Address - Fax:978-851-9033
Practice Address - Street 1:1501 MAIN ST
Practice Address - Street 2:UNIT 2
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-4725
Practice Address - Country:US
Practice Address - Phone:978-851-9055
Practice Address - Fax:978-851-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA97111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA689907OtherTUFTS HEALTH PLAN
MAY39244OtherBCBS OF MA
MA0005455Medicare PIN