Healthcare Provider Details

I. General information

NPI: 1689784282
Provider Name (Legal Business Name): BRIAN MORIN PTA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 OSSIPEE TRL E SUITE 1151
STANDISH ME
04084-6464
US

IV. Provider business mailing address

95 BUCK ST
GORHAM ME
04038-2201
US

V. Phone/Fax

Practice location:
  • Phone: 207-642-5325
  • Fax: 207-642-5395
Mailing address:
  • Phone: 207-650-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPA3126
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: