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General NPI Number Information
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NPI Number | 1205924529
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Entity Type | Organization
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Legal Business Name | CAPITAL CITY CHIROPRACTIC PC
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 03/25/2014
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Provider Practice Location Address
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Address Line | 66 EASTERN AVE
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City | AUGUSTA
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State | ME
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Zip | 04330-5837
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Country | US
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Telephone | 207-620-8291
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Fax | 207-620-8292
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Provider Business Mailing Address
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Address Line | 66 EASTERN AVE
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City | AUGUSTA
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State | ME
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Zip | 04330-5837
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Country | US
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Telephone | 207-620-8291
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Fax | 207-620-8292
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TRAVIS A GRONDIN
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Credential | D.C.
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Telephone | 207-620-8291
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CR1652
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License Number State | ME
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