=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386781235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE CHIROPRACTIC & REHABILITATION, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 DARTMOUTH ST SUITE A
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-828-8777
-----------------------------------------------------
Fax | 207-828-8778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 COVE ST SUITE 101
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-2514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-828-8777
-----------------------------------------------------
Fax | 207-828-8777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, OWNER
-----------------------------------------------------
Name | GARRETT R LEWELLEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 207-828-8777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CR 1311
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------