Healthcare Provider Details

I. General information

NPI: 1154096238
Provider Name (Legal Business Name): SACO BAY ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 STILLWATER AVE STE 5
OLD TOWN ME
04468-2215
US

IV. Provider business mailing address

4714 GETTYSBURG RD
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-0214
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MICHAEL E TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100