Provider Demographics
NPI:1386898625
Name:MDDC, LLC
Entity type:Organization
Organization Name:MDDC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:YALICH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:410-238-0140
Mailing Address - Street 1:3 NASHUA CT
Mailing Address - Street 2:SUITE H
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21221-3133
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:410-933-3923
Practice Address - Street 1:3 NASHUA CT
Practice Address - Street 2:SUITE H
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3133
Practice Address - Country:US
Practice Address - Phone:410-933-5678
Practice Address - Fax:410-933-3923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD151915OtherMEDICARE PTAN
MD1386898625OtherNPI