Healthcare Provider Details

I. General information

NPI: 1790795193
Provider Name (Legal Business Name): BRIDGTON CHIROPRACTIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 PORTLAND RD
BRIDGTON ME
04009-1230
US

IV. Provider business mailing address

55 PORTLAND RD
BRIDGTON ME
04009-1230
US

V. Phone/Fax

Practice location:
  • Phone: 207-647-3504
  • Fax: 207-647-5862
Mailing address:
  • Phone: 207-647-3504
  • Fax: 207-647-5862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCR755
License Number StateME

VIII. Authorized Official

Name: DR. STEWART ESTABROOK SULLOWAY
Title or Position: DOCTOR OF CHIROPRACTIC, PRESIDENT
Credential: D.C.
Phone: 207-647-3504