Provider Demographics
NPI:1558532697
Name:MAIN STREET CHIROPRACTIC
Entity type:Organization
Organization Name:MAIN STREET CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:BROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-924-8558
Mailing Address - Street 1:182 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4409
Mailing Address - Country:US
Mailing Address - Phone:617-924-8558
Mailing Address - Fax:617-924-8559
Practice Address - Street 1:182 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-4409
Practice Address - Country:US
Practice Address - Phone:617-924-8558
Practice Address - Fax:617-924-8559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty