Provider Demographics
NPI:1386825776
Name:PINE GROVE CHIROPRACTIC, P.C.
Entity type:Organization
Organization Name:PINE GROVE CHIROPRACTIC, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUPHILY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:508-998-8444
Mailing Address - Street 1:934 ASHLEY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745
Mailing Address - Country:US
Mailing Address - Phone:908-998-8444
Mailing Address - Fax:508-998-9777
Practice Address - Street 1:934 ASHLEY BOULEVARD
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745
Practice Address - Country:US
Practice Address - Phone:908-998-8444
Practice Address - Fax:508-998-9777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39254OtherBLUE CROSS/BLUE SHIELD MA
MA1611666Medicaid
MAY39254OtherBLUE CROSS/BLUE SHIELD MA