Healthcare Provider Details

I. General information

NPI: 1023002243
Provider Name (Legal Business Name): THOMAS STEPHEN BOURDON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 BIRCH ST
LEWISTON ME
04240-6408
US

IV. Provider business mailing address

80 ANDROSCOGGIN AVE APT 1
LEWISTON ME
04240-6606
US

V. Phone/Fax

Practice location:
  • Phone: 207-333-3236
  • Fax: 207-783-3347
Mailing address:
  • Phone: 207-671-5016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATC185
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: