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General NPI Number Information
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NPI Number | 1699940205
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Entity Type | Organization
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Legal Business Name | THE SPORTS THERAPY CENTER LLC
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Dates
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Enumeration Date | 04/24/2008
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Last Update Date | 04/24/2008
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Provider Practice Location Address
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Address Line | 222 AUBURN ST SUITE # 103
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City | PORTLAND
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State | ME
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Zip | 04103-6002
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Country | US
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Telephone | 207-221-3254
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Fax |
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Provider Business Mailing Address
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Address Line | 16 CROSSMEADOW RD
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-6853
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Country | US
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Telephone | 207-415-5621
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. GARRY G BRACKEN
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Credential | D.C.
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Telephone | 207-221-3254
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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 | CR1160
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License Number State | ME
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