Provider Demographics
NPI:1699067843
Name:OLD PORT CHIROPRACTIC,INC.
Entity type:Organization
Organization Name:OLD PORT CHIROPRACTIC,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-749-8736
Mailing Address - Street 1:97A EXCHANGE ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-5016
Mailing Address - Country:US
Mailing Address - Phone:207-749-8736
Mailing Address - Fax:
Practice Address - Street 1:97A EXCHANGE ST STE 204
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5016
Practice Address - Country:US
Practice Address - Phone:207-749-8736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1254261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service