Healthcare Provider Details

I. General information

NPI: 1093722670
Provider Name (Legal Business Name): TRAVIS ALAN GRONDIN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 EASTERN AVE
AUGUSTA ME
04330-5837
US

IV. Provider business mailing address

66 EASTERN AVE
AUGUSTA ME
04330-5837
US

V. Phone/Fax

Practice location:
  • Phone: 207-620-8291
  • Fax:
Mailing address:
  • Phone: 207-620-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCR1652
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: