Provider Demographics
NPI:1366597536
Name:WEST ROXBURY CHIROPRACTIC
Entity type:Organization
Organization Name:WEST ROXBURY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:617-323-5040
Mailing Address - Street 1:20 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-2339
Mailing Address - Country:US
Mailing Address - Phone:978-394-2147
Mailing Address - Fax:
Practice Address - Street 1:20 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-2339
Practice Address - Country:US
Practice Address - Phone:978-394-2147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA495231OtherTUFTS
MAAA69927OtherHARVARD PILGRIM
MAY40094OtherBLUE CROSS BLUE SHIELD
MA1603230Medicaid
MAT58100Medicare UPIN
MAY35319Medicare PIN