Provider Demographics
NPI:1790795193
Name:BRIDGTON CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:BRIDGTON CHIROPRACTIC CENTER, INC.
Other - Org Name:ESTABROOK SULLOWAY, D.C.
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:ESTABROOK
Authorized Official - Last Name:SULLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-647-3504
Mailing Address - Street 1:55 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1230
Mailing Address - Country:US
Mailing Address - Phone:207-647-3504
Mailing Address - Fax:207-647-5862
Practice Address - Street 1:55 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1230
Practice Address - Country:US
Practice Address - Phone:207-647-3504
Practice Address - Fax:207-647-5862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR755111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M20915OtherCIGNA #
234252OtherAETNA #
ME039429OtherANTHEM/BCBS #
M20915OtherCIGNA #
BR-Y49199Medicare ID - Type UnspecifiedGROUP NUMBER
MM2418Medicare ID - Type UnspecifiedINDIVIDUAL DR NUMBER