Provider Demographics
NPI:1588759039
Name:GREATER LOWELL CHIROPRACTIC REHABILITATION INC
Entity type:Organization
Organization Name:GREATER LOWELL CHIROPRACTIC REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BRODERICK
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:978-452-1466
Mailing Address - Street 1:249 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2214
Mailing Address - Country:US
Mailing Address - Phone:978-452-1466
Mailing Address - Fax:978-452-1826
Practice Address - Street 1:249 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2214
Practice Address - Country:US
Practice Address - Phone:978-452-1466
Practice Address - Fax:978-452-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPR1697Medicaid
MA468952OtherTUFTS
MA63563OtherFALLON
MAY36807OtherBLUE CROSS/BLUE SHIELD
MA351369OtherHARVARD PILGRIM
MA606350OtherCIGNA
MAPR1697Medicaid