Healthcare Provider Details

I. General information

NPI: 1174274492
Provider Name (Legal Business Name): GARRETT RIFE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 UNION ST
BANGOR ME
04401-3051
US

IV. Provider business mailing address

120 7TH ST
OLD TOWN ME
04468-1643
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-9980
  • Fax:
Mailing address:
  • Phone: 717-658-7973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT833
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: