Provider Demographics
NPI:1558372938
Name:BRACKEN, GARRY G (DC)
Entity Type:Individual
Prefix:
First Name:GARRY
Middle Name:G
Last Name:BRACKEN
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 1:96 INDIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4230
Mailing Address - Country:US
Mailing Address - Phone:207-775-6782
Mailing Address - Fax:
Practice Address - Street 1:96 INDIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4230
Practice Address - Country:US
Practice Address - Phone:207-775-6782
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR1160111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME2943218OtherAETNA
ME038957OtherANTHEM
ME8504386OtherCIGNA