Provider Demographics
NPI:1093722670
Name:GRONDIN, TRAVIS ALAN (DC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ALAN
Last Name:GRONDIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5837
Mailing Address - Country:US
Mailing Address - Phone:207-620-8291
Mailing Address - Fax:
Practice Address - Street 1:66 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5837
Practice Address - Country:US
Practice Address - Phone:207-620-8291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME2172Medicare UPIN
MEME2171Medicare UPIN