Healthcare Provider Details

I. General information

NPI: 1881709277
Provider Name (Legal Business Name): BOB G. NESIBA D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 BUCKSPORT RD
ELLSWORTH ME
04605-2224
US

IV. Provider business mailing address

150 BUCKSPORT RD
ELLSWORTH ME
04605-2224
US

V. Phone/Fax

Practice location:
  • Phone: 207-667-4678
  • Fax: 207-843-6059
Mailing address:
  • Phone: 207-667-4678
  • Fax: 207-843-6059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberCR430
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: