Healthcare Provider Details

I. General information

NPI: 1982142048
Provider Name (Legal Business Name): 207 CHIROPRACTIC PAIN CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 COLUMBIA ST SUITE 11
BANGOR ME
04401-6346
US

IV. Provider business mailing address

43 COLUMBIA ST SUITE 11
BANGOR ME
04401-6346
US

V. Phone/Fax

Practice location:
  • Phone: 207-307-7413
  • Fax: 844-813-8498
Mailing address:
  • Phone: 207-307-7413
  • Fax: 844-813-8498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberCR2341
License Number StateME

VIII. Authorized Official

Name: DR. CHUCK JONATHAN LEBLANC
Title or Position: OWNER
Credential: DC
Phone: 207-307-7413