Provider Demographics
NPI:1437331311
Name:BERRY CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:BERRY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-620-4100
Mailing Address - Street 1:176 THOMAS JOHNSON DR
Mailing Address - Street 2:#204
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4410
Mailing Address - Country:US
Mailing Address - Phone:301-620-4100
Mailing Address - Fax:
Practice Address - Street 1:176 THOMAS JOHNSON DR
Practice Address - Street 2:#204
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4410
Practice Address - Country:US
Practice Address - Phone:301-620-4100
Practice Address - Fax:301-420-1407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01420111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KP25BEOtherCAREFIRST BCBS MARYLAND
3831919OtherCIGNA
223239OtherMAMSI
W375-0001OtherCAREFIRST BCBS FEP
W375-0001OtherCAREFIRST BCBS FEP