Healthcare Provider Details

I. General information

NPI: 1669052601
Provider Name (Legal Business Name): MID-COAST SPINE & SPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 WISCASSET RD STE 4
BOOTHBAY ME
04537-4618
US

IV. Provider business mailing address

PO BOX 355
BOOTHBAY ME
04537-0355
US

V. Phone/Fax

Practice location:
  • Phone: 207-315-6388
  • Fax: 207-315-6359
Mailing address:
  • Phone: 207-315-6388
  • Fax: 207-315-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: BRADY ROBERT FERGOLA
Title or Position: OWNER
Credential:
Phone: 207-633-5500