Provider Demographics
NPI:1376765750
Name:OLD ORCHARD BEACH CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:OLD ORCHARD BEACH CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:207-934-4600
Mailing Address - Street 1:155 SACO AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-1600
Mailing Address - Country:US
Mailing Address - Phone:207-934-4600
Mailing Address - Fax:207-934-4606
Practice Address - Street 1:155 SACO AVE STE A2
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-1600
Practice Address - Country:US
Practice Address - Phone:207-934-4600
Practice Address - Fax:207-934-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME023110OtherBLUE CROSS BLUE SHIELD
ME023110OtherBLUE CROSS BLUE SHIELD