Basic Information
| Provider Information | |||||||||
| NPI: | 1093909715 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERICA L POLLACK | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240150127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409819394 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 3609 BLUE RIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | BLUE RIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240641976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409774611 | ||||||||
| FaxNumber: | 5409774611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 06/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | POLLACK | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5409774611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 0104001490 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 5968516 | 01 | AETNA | OTHER | 222164 | 01 | ANTHEM | OTHER | 2128060 | 01 | MAMSI | OTHER |